LIBRARY OF CONGRESS. 



Shelf,...B...2r'S 

UNITED STATES OF AMEKICA. 



9 \88tj 



4 



A TREATISE 



ON THE 



PRACTICE OF MEDICINE 



FOR THE USE OF 



STUDENTS AND PRACTITIONERS OF MEDICINE 



BY 

ROBERTS BARTHOLOW, M.A., M.D., LL.D., 

Professor of Materia Medica, General Therapeutics, and Hygiene, in the JeflFerson Medical College 
of Philadelphia, and Dean of the Faculty; formerly Professor of the Theory and Practice 
of Medicine in the Medical College of Ohio, Cincinnati ; Fellow of the College of 
Physicians of Philadelphia ; Member of the American Philosophical Society ; Honorary 
Member of the Medical and Chii-urgical Faculty of Maryland, of the New- 
York, Yirginia, and Ohio State Medical Societies; of the Societe MedicO' 
/ Pratiques de Paris, etc. ; Author of a Treatise on Materia Medica 

^^^^^^r"-"^ and Therapeutics, of a Treatise on Medical Electricity, and of a 
"""^ Manual of Hypodermatic Medication ; Cartwright Lecturer 

iX- A ^t)^ for ISSl, of the Alumni Association of the College 
J / of Physicians and Surgeons of Xew York, etc. 



8IXm EDITION, REVISED AND ENLARGED 




NEW YOEK 



D. APPLETOIT Kl^J) COMPAITY 
1886 




Copyright, 1880, 1881, 1882, 1883, 1886, 
D. APPLETON AND COMPANY. 



3 JDebicate 

THIS EDITION OF MY 
TREATISE ON THE PRACTICE OF MEDICINE 
TO THE MEMORY OF MY DEAR FRIEND 

E. K. SPRIXGER, 

OF CINCINNATI, OHIO. 



PEEFAOE TO THE SIXTH EDITIOK 



In preparing this edition of my Treatise on the Practice of 
Medicine, I have sought to make it still more worthy the approba- 
tion of my readers. In no way can this purpose be more certainly 
assured than by increasing its practical resources, l^ot overlooking 
the advances made in scientific medicine, I have, however, devoted 
most attention to the clinical aspects of the subject. In developing 
this purpose, I have tried to preserve that harmony and proportion, 
in the treatment of the various topics, so necessary in a systematic 
treatise. It has been imperative, to keep in view my original de- 
sign, to prepare a work in three volumes, which should cover the 
whole domain of special pathology and therapeutics. 

I had not dared to mention so ambitious a purpose until two 
of these volumes — Materia Medica and Therapeutics, Practice of 
Medicine — had appeared and been favorably received. The third of 
this series, intended to treat of the Principles of Medicine, is now 
in course of that careful and deliberate preparation necessary in the 
treatment of such an important subject. While each one is an 
independent work, they are expected to be mutually complementary. 
In executing so large an undertaking, it is necessarily difficult to 
preserve a proper proportion in its various parts. I can not flatter 
myself that I have entirely overcome this difficulty. 

In the present edition some new subjects have been introduced, 
and preliminary chapters have been appended to the chief divisions 
of the work, to make the study of the diseases of the class more 



vi 



PREFACE TO THE SIXTH EDITION. 



exact, and to enJiance tlie practical character of the whole. I be- 
lieve I may saj that little, properly pertaining to the domain of 
practice, has been overlooked, and that nothing superfluons has been 
admitted. That the work might have been written from a different 
standpoint is quite true, but then its character had been changed. 
As the purpose was to prepare a concise, practical treatise, to be 
independent in itself, and yet form a part of a larger whole, the 
subject must necessarily be discussed as has been done here. That 
some of my critics think differently, because they have conceived 
another ideal, is inevitable, but any regret I might have over this 
disapproval of my plans is quite tempered by the reflection that I 
am not striving to placate such critics so much as to please myself, 
and especially the large body of my sympathetic readers, whose ap- 
proval is testified in the disappearance of successive large editions 
of the work. To them I repeat the assurance of my gratitude for 
the favor with which they have received my contributions to the 
Practice of Medicine. 

E. B. 

Philadelphia, 1527 Locust Street, 
July i, 1886. 



PEEFAOE TO THE FIETH EDITIOK 



Again there is imposed on me the grateful diitj of acknowl- 
edging my indebtedness to numerous readers for their imf ailing 
apjDreciation of my work. 

The fifth edition has followed so soon on the fourth that but 
few changes are necessary; yet these happen to be important. 
The bacillus tuberculosis has been discovered, and minute organ- 
isms are increasing in pathogenetic importance. Any work pre- 
suming to represent the present state of medical knowledge can 
not be unmindful of such topics. Some other changes and addi- 
tions have been made — ^in all, increasing the size of the work by 
about twenty pages. 

In submitting this edition to the medical public, I can do no 
less than reiterate the expression of my hope that it may con 
tinue to enjoy the favor bestowed on the work from its first issue^ 

EOBEETS BaKTHOLOW. 



1509 Walnut Strekt, Philadelphia, 
April 15, 1883. 



PEEFAOE TO THE THIED EDITIOK 



If tlie rapid sale of large editions of a work may indicate 
that it supplies the needs of many readers, I ought to be satisfied 
"with the measure of success to which this treatise has attained. 
That it is fulfilling its mission is demonstrated to me in the en- 
couraging, even enthusiastic expressions of approval, coming from 
numerous correspondents, who have found in this work a safe 
guide and judicious counselor. It is especially gratifj^ng that 
those who have followed modes of treatment here inculcated 
have not been disappointed in the results. This fact seems to 
be a sufficient answer to those pessimistic critics who have found 
the author over-sanguine and dogmatic in his statements on thera- 
peutical points. 

That the confidence and esteem of my readers may continue 
to be justified, I have sought, in this edition, to make my work 
more thorough by adding some new articles, and by subjecting 
the whole to a careful revision. About fifty pages have been 
added, thus enlarging the scope, and, I hope, increasing the utility 
of the book. It does not yet approximate in its dimensions to 
the standard of those critics who estimate a work according to 
its weight, or to the number of its pages. As the author de- 
spairs of propitiating the favor or of conforming to the views 
of such critics, he must needs bear as best he can the weight 
of their displeasure. He is, however, supported in the midst of 
this trial by the circumstances that his work has been very fa- 



X 



PKEFACE TO THE THIRD EDITION. 



vorablj judged by the most influential organs of professional 
opinion printed in the EngHsh language, and that it is now being 
translated into Chinese, for the use of the physicians of the 
Celestial Empire. Those characteristics of the work to which 
its popularity seems to be due are its directness, its brevity, and 
yet the sufficient detail in which the various topics have been 
treated. In the new articles the same method of exposition has 
been followed. I may, therefore, anticipate, I hope, that the third 
and improved edition will continue to enjoy the favor so gen- 
erously bestowed on former issues. 

The author has been furnished by various correspondents with 
the results of treatment, as obtained by them from the methods 
prescribed in the therapeutical sections. It is desirable to accu- 
mulate facts, and hence failures should be reported as well as 
successes. It is also desirable to ascertain if the results of drug 
administration correspond to the pretensions of therapeutists. Is 
the optimism of the positive school justified by the deductions 
of clinical experience? I hope that those of my readers who 
are making observations will publish them, in the interests of 
scientific truth, to silence the cavils of therapeutical nihilists on 
the one hand, or the claims of therapeutical optimists on the 
other. 

KOBEETS BaETHOLOW. 

1509 "WALimT Street, Philadelphia, 
January^ 1882. 



PEEFACE TO THE SEOOND EDITIOisT, 



In less than one month after the publication of the first edition 
of three thousand copies of this treatise, the publishers called on 
me to prepare a second edition. This result is the more surprising, 
as it was accomphshed before the numerous medical journals of the 
country had introduced the book to their readers, and pronounced 
a judgment on its merits or defects. I feel deeply grateful to my 
numerous readers for this substantial evidence of their appreciation 
of my labor. I have, also, a great many correspondents, in all parts 
of the country, to thank for kind expressions of approval, and for 
valuable suggestions. 

In this edition I have corrected some typographical errors which 
escaped notice, and have amended some doubtful statements, and 
also have added articles on Alcoholism and on Sunstroke — topics 
overlooked in preparing the first edition. I have, further, enlarged 
the index, and have added an index of authors. In the first preface 
it was stated that I had avoided an attempt at bibliographical dis- 
play, w^hich has perplexed some of my bibliolatrous critics. One of 
them, in a notice of the work, was pleased to observe that I had 
condensed my materials from the text-books and cyclopaedias. 
While expressly disclaiming an attempt to give a complete, even a 
full bibliography, I have indexed the authors referred to in the 
body of the work, which will show that I went to original sources 
for my information. Almost all of the works, monographs, and 
articles referred to, are contained in my own library of three thou- 



xii 



PKEFACE TO THE SECOND EDITION. 



sand medical volumes ; and those not in my own were obtained 
from the library of the College of Physicians of this city. I wish 
my book, however, to be regarded, as it should justly be, the prod- 
uct of my own study, observation, and experience. An author with 
any training in the methods of authorship will agree with me, that 
to prepare a work, every detail of which the writer has made his 
own, is greatly more laborious than merely compiling a work from 
abundant bibliographical resources. I could more easily have pre- 
pared two volumes from the materials at hand, than write this 
book ; but it was not my purpose to merely compile a book on 
practice — rather to prepare one which contained my own concep- 
tion of the subject. I venture to express the conviction that, the 
more carefully this work is examined, the more it will be found to 
contain the most recent and approved facts of special pathology and 
therapeutics, without verbose dilution, and literary and typographi- 
cal padding. With the hope that the second edition will continue 
to enjoy the favor accorded to the first, I submit it to the discrimi- 
nating judgment of the medical profession. 

EOBERTS BaETHOLOW. 



Philadelphia, 1509 Walnut Street, 
November 1, 1880. 



P E E F A 0 E. 



In undertaking the preparation of a treatise on the Practice of 
Medicine, I liad the intention to write a companion volume to mj 
work on Materia Medica and Therapeutics. When announced, the 
book was so far advanced that its completion was confidently anti- 
cipated within the year. Unfortunately, the condensation of mate- 
rial found necessary, when the work had reached that stage where 
its proportions could be judged with some accuracy, involved much 
additional labor. This was the more regrettable, as the incessant 
demands of a large private practice and the onerous duties of an 
exacting professorial position permitted little of that uninterrupted 
leisure which is essential for successful literary composition. Slow 
progress was inevitable under these circumstances, and hence it was 
not until my removal to Philadelphia last year that I could devote 
some hours each day to my arduous task. I trust that this explana- 
tion of the delay in the appearance of the treatise will be satisfac- 
tory to my readers, especially to the large number who have hon- 
ored me by subscribing for the work long in advance of its publi- 
cation. 

As my treatise on Materia Medica and Therapeutics embraced 
those topics of importance to the physician, and omitted matters of 
rather extraneous interest, so in the preparation of this volume my 
purpose was to include the subjects embraced under the title of 
" Practice of Medicine," omitting those topics of general pathology, 
etiology, etc., with which the works on Practice usually open, and 



xiv 



PREFACE. 



which, though sufficiently valuable in themselves, are too often 
passed over hastily, or not read at all, in the desire to reach the 
practical subjects. I have therefore omitted the topics in question 
from their position as an introduction to special pathology, and 
have, although at the disadvantage of some repetition, incorporated 
them in their proper relation with individual diseases. 

That I should, under all the circumstances above stated, have 
undertaken such a task as the preparation of this treatise, for which, 
it may be suggested, there was no special need, and, if the need ex- 
isted, there was no claim on me to supply it, may be accounted for 
by the fact that, when the work was begun, I was Professor of the 
Theory and Practice of Medicine and of Clinical Medicine in the 
Medical College of Ohio, and was urged, not only by the students 
and practitioners who attended my lectures, but also by many read- 
ers of my therapeutical treatise, to prepare a volume on Practice, 
which should have the practical characteristics, the definiteness of 
statement, the conciseness, and, at the same time, the fullness of 
the work on Materia Medica and Therapeutics. I was the more 
inclined to accede to these wishes because of a natural desire to ap- 
pear as an author on subjects to which I had devoted all the years 
of my professional life, and under the most varied conditions. 
Serving as an officer of the medical staff of the United States Army 
in Kansas, Utah, Colorado, l^ew Mexico, Minnesota, and during the 
war of the rebellion at Washington, Nashville, Chattanooga, Balti- 
more, etc., followed by an extensive practice (private and hospital) 
of sixteen years at Cincinnati, I may justly claim to have enjoyed 
large opportunities for the clinical study of the diseases of the 
l^orth American Continent. With one or two unimportant excep- 
tions, I have had personal charge of the maladies treated of in this 
work, and have made them the subject of clinical demonstration 
or jpost-mortem investigation, either privately or in public lectures. 

In the treatment of the various topics, I have attempted to give 
to each just that amount of consideration to which its importance 
entitles it, within the limitations imposed by the size of the work. 
A just harmony and proportion can be secured only by condensing 
some subjects and displaying others. ISTo space has been given to 
merely historical disquisitions, or to the discussion of controverted 



PREFACE. 



XV 



points. Also, to utilize all available space, chapters liave been dis- 
pensed with, and the intervals between the sections have been ab- 
breviated as much as possible. jSTotwithstanding mj utmost efforts 
at condensation, the work has grown beyond the contemplated size ; 
but I would fain hope that no part of it could be sacrificed without 
impairing the value of the whole. 

Much of the matter embraced in a work of this kind is the 
common property of the medical profession, and hence I have not 
quoted many authorities. I have rather avoided references when 
their mention would have been mere pedantry, and would have 
occupied valuable space. Nevertheless, when I was distinctly in- 
debted for some fact or opinion, I have given the reference to the 
authority. Sometimes, when the authority is well known, the 
name is merely inclosed in parentheses. It is a comparatively easy 
task, especially with the aids now at our disposal, to give an ex- 
tended bibliography, but the space occupied would have swollen 
this work to encyclopedic proportions, without adding to its real 
utility. When an author only expresses the opinions of his author- 
ities, he avoids the appearance of dogmatism, which must be the 
tone of a work giving utterance to indi\T.dual opinions ; but I could 
hardly do otherwise than draw my clinical material — the descrip- 
tions of diseases — from my own observations at the bedside. Also, 
a large experience in the treatment of disease could not fail to 
develop some positive convictions as to the real value of remedies. 
The reader will find that I have no sympathy with the therapeu- 
tical nihilism of the day, and that my convictions find expression 
in the recommendation of plans of treatment. In a work of this 
kind, intended for the guidance of young practitioners and students, 
some dogmatism, although offensive to the highest taste, may be 
pardoned, in view of the practical advantages of experienced leader- 
ship. Indeed, there is no department of the subject in which it 
seemed to me so necessary to express positive opinions. The influ- 
ence of some of our most prominent medical thinkers has been 
opposed to the value of medicines in the treatment of disease. 
The modern school of pathologists, absorbed in the contemplation 
of the ravages of diseases, are either oblivious of the curative 

powers of remedies, or openly ridicule the pretensions of thera- 
2 



xvi 



PREFACE. 



peutists. I have, therefore, in the therapeutical sections, especially 
endeavored to set forth true principles, and have taught the utility 
of drugs when rightly administered, but have none the less tried 
to indicate the limits of their utility, for he v^ho is unmindful of 
the injury done by ill-directed or reckless medication is as unsafe a 
guide as the most pronounced therapeutical nihilist. 

The pathological doctrines inculcated in the work are derived 
from the highest sources. The few illustrations of morbid changes 
introduced were obtained from the admirable atlas of Thierfelder. 
As my information on this subject was derived from those best 
qualified to instruct, I have not hesitated to express with some 
decision the present state of knowledge in respect to the pathology 
of the various diseases, desiring in this, as in other departments of 
my subject, to give som.e positive views. I may be criticised with 
the observation that, in the progress of discovery, the doctrines at 
present received unreservedly may be entirely overthrown, and 
very different views be substituted. It will be time enough, how- 
ever, when the change comes, to adapt our opinions to the new 
order of pathological doctrines. 

Having thus explained my intentions in producing the work, 
I submit it to the judgment of the medical profession, with the 
assurance that, whether favorable or unfavorable, the decision will 
be just. 

EOBEETS BaRTHOLOW, 

1509 Walnut Street, Philadelphia, 
September, 1880. 



TABLE OF COlSrTElsrTS. 



SPECIAL PATHOLOGY AND THERAPEUTICS. 

LOCAL DISEASES. 

PAGE 



Diseases of the Digestiye System ...... 1 

Topography of the Abdomen : Physical Exploration .... 1 

Stomatitis .......... 4 

Aphthous ......... 5 

Muguet ......... 6 

Glossitis ......... 8 

Superficial ......... 9 

Deep ......... 10 

Tonsillitis . . . . , . . . . .12 

Gangrene of the Mouth ....... 17 

Noma . . . . . . . . . .17 

Catarrh of Naso-pharyngeal Mucous Membrane . . . . 19 

Catarrh of Lower Pharynx . . . . , . .21 

Retro-pharyngeal Abscess 22 

Diseases of the CEsophagus . . . . . . .23 

(Esophagitis ......... 23 

Dysphagia .......... 24 

Stenosis of the ffisophagus ....... 25 

Dilatations of the (Esophagus . . . . . . .26 

Diseases of the Stomach ....... 27 

Acute Gastritis . . . . . . . . . 28 

Toxic Gastritis . . . . . . . . 31 

Phlegmonous Gastritis ........ 33 

Chronic Gastric Catarrh ....... 33 

Atonic Dyspepsia ......... 39 

Gastralgia ......... 41 

Ulcer of the Stomach . . . . . . . .44 

Carcinoma of the Stomach ....... 52 

Heematemesis ......... 60 

Dilatation of the Stomach ....... 64 

Diseases of the Intestine ........ 66 

Catarrh of the Intestine ....... 66 

Cholera Morbus 68 
Infantum 71 
Duodenitis ....»,.... 75 



xviii 



CONTENTS. 



PAGE 



Ileitis ...... o ... TS 

Ileo-colitis . . . , . o . . . . 78 

Typhlitis ...... o . . 81 

Inflammation of the Appendix Vermiformis . . , . .86 

Perityphlitis . . . . . . . . . 86 

Proctitis — Catarrh of the Eectum . . . . . . .87 

Croupous Enteritis . . . . . . . . 91 

Dysentery .......... 94 

Ulcers of the Intestines ....... 103 

Cancer of the Intestines ........ 108 

Intestinal Haemorrhage . . . . . . . Ill 

Enteralgia .......... 112 

Constipation . . . . . . . . . 114 

Obstruction of the Intestines . . . . . . .120 

Intestinal Parasites . . . . . . , . 131 

Cestoda ......... 132 

Taenia Solium . . . . . . .• .132 

Tffinia Saginata . » . . . . . .134 

Bothriocephalus Latus ....... 137 

Nematoda . . . . . . . . .138 

Ascaris Lumbricoides . . , . . . 138 

Oxyurus Vermicularis ....... 141 

Trichocephalus . . . . . . .141 

Diseases op the Peritoneum ....... 143 

Peritonitis . . . . . . . . . 143 

Ascites .......... 150 

Diseases of the Pancreas . . . . . . .154 

Pancreatitis ......... 155 

Subacute . . . . . . . . . 156 

Cancer of the Pancreas ... . . • . . 158 

Cysts of the Pancreas . . . . . . . .159 

Calculi ■ . .159 

Diseases op the Liver ........ 160 

Topography of the Liver . . . . . . . .160 

Composition of and Tests for Bile ...... 162 

Jaundice .......... 163 

Congestion of the Liver . . . . . . .169 

Interstitial Hepatitis . . . . . . . .174 

Sclerosis . . . . . . . . . 174 

Abscess of the Liver . . . . . . . .181 

Acute Yellow Atrophy . . . , . . . . 191 

Amyloid Liver ......... 195 

Carcinoma of the Liver . . . . . • .199 

Echinococcus of the Liver ....... 202 

Aneurism of the Hepatic Artery ...... 208 

Thrombosis of the Portal Vein . . . . . . • 208 

Suppurative Pylephlebitis ....... 209 

Catarrh of the Bile-Ducts . . . . . . • .210 

Occlusion of the Biliary Passages 214 
Biliary Calculi ......... 215 

Diseases of the Spleen o . . o . • ^ 220 

Topography of the Spleen ....... 22C 



CONTENTS. 



xix 



PAGE 

Acute Splenitis . = . . . , . . .220 

Enlargement of the Spleen o . . = . . , 222 

Misplaced Spleen ......... 223 

A.myloid Degeneration of the Spleen . . .. . . . 224 

Echinococcus of the Spleen ....... 224 

Diseases of the Blood-forming Organs ..... 225 

The Blood . . . . . . . . . .225 

Leucocythemia ........ 229 

Addison's Disease ......... 235 

Melanemia ......... 241 

Hsemophilia . . . . . . . . . 242 

Scorbutus ......... 246 

Purpura .......... 251 

Anaemia ......... 254 

Chlorosis ........... 260 

Progressive Pernicious Anaemia .... . 263 

Thrombosis and Embolism ....... 265 

Diseases of the Heart . . . . . . . 269 

Topography of the Cardiac Region .... . 269 

Pericarditis ......... 2*73 

Adhesions of the Pericardium ....... 283 

Hydropericardium ........ 285 

Hydropneumopericardium . . . . . . . . 286 

Myocarditis . . . . . . . . 287 

Fatty Degeneration ........ 290 

Rupture of the Heart ........ 293 

Hypertrophy and Dilatation ....... 294 

Plastic Endocarditis ........ 301 

Ulcerative Endocarditis ...... . . 305 

Diseases of the Yalves and of the Orifices . . . . . 309 

Affections of the Aortic Yalves and Orifice . . . . .314 

Affections of the Mitral Yalves and Orifice ..... 317 

Affections of the Tricuspid Yalves and Orifice ..... 320 

Affections of the Pulmonary Yalves and Orifice .... 322 

Heart-Clots .......... 328 

Palpitation of the Heart ....... 330 

Diseases of the Blood-Yessels . . . . . . . 332 

Arteritis . . . . . . . . . 332 

Aneurism of the Aorta . . . . . . . .836 

Diseases of the Respiratory Organs ..... 349 

Topography of the Chest . . ' . . . . . . 349 

Physical Diagnosis . . . . . . . . 349 

Pleuritis . . . . . . . . . .355 

Hydrothorax ......... 369 

Pneumothorax . . . . . . , . . 371 

Hydropneumothorax . . . . . . . .371 

Pneumonia . . . . . . . . . . 376 

Embolic Pneumonia . . . . , . . 392 

Catarrhal Pneumonia . . . . , . . .394 

Phthisis Pulmonalis . . . . . . , . 401 

Caseous ......... 402 

Tubercular . ^ . . , , . , 406 



XX 



CONTENTS. 



PAGE 

Phthisis Pulmonalis, Fibroid . . . . . , . 416 

Haemoptysis ......... 427 

Eypersemia and (Edema of the Lungs . . o . . . 433 
Atelectasis of the Lungs . . . . . . .437 

Emphysema of the Lungs ........ 440 

Gangrene of the Lungs ....... 448 

Carcinoma of the Lungs ........ 452 

Echinococci of the Lungs . . . . . . . 454 

Acute Bronchitis ......... 456 

Chronic Bronchitis . . . . . . . .461 

Croupous Bronchitis . . . . . . . .465 

Stenosis of Trachea and Bronchi ...... 469 

Asthma .......... 470 

Diseases of the Larynx 476 

Acute Laryngitis ......... 476 

Chronic Laryngitis . . . , . . . . 478 

(Edema of the Glottis . . . . . . . .480 

Laryngeal Phthisis ........ 483 

Syphilis of the Larynx ........ 486 

Perichondritis of the Larynx . . . . . . . 488 

Tumors of the Larynx ........ 489 

Laryngismus Stridulus . . . . . . . .491 

Croupous Laryngitis (True Croup) ....... 493 

Coryza .......... 499 

Epistaxis .......... 602 

Diseases of the Kidney ....... 503 

The Urine — Its Composition ....... 503 

Tests for Albumin ........ 508 

Tests for Sugar ......... 510 

Uraemia . . . . . . . " . . 511 

Congestion of the Kidneys, active ....... 515 

Congestion of the Kidneys, passive ...... 516 

Acute Parenchymatous Nephritis . . . . . . ,517 

Acute Parenchymatous Nephritis of Pregnancy .... 522 

Chronic Parenchymatous Nephritis ...... 524 

Interstitial Nephritis 528 

Hgematinuria ......... 536 

Amyloid Kidney ........ 538 

Pyelitis and Pyelonephritis . . . . . . . 543 

Renal Calculi ......... 546 

Hydronephrosis . . . . ' . . . . . 553 

Carcinoma of the Kidney . . . , . . . 655 

Tuberculosis of the Kidney ....... 558 

Echinococcus of the Kidney ....... 559 

Movable Kidney . ........ 662 

Perinephritis ......... 564 

Diseases op the Nervous System . . . . . . . 566 

Clinical Examination ........ 566 

Cerebral Hypersemia ........ 574 

Anaemia ......... 578 

Occlusion of the Cerebral Vessels ....... 681 

Obliteration of the Capillaries 586 



CONTENTS. 



xxi 



PAGE 

Occlusion of the Sinuses . » . » . . . . 58*7 

Cerebral Haemorrbage . . . . . . . . 589 

Meningeal ......... 596 

Pachymeningitis . . . . . . . . 597 

Externa ......... 597 

Interna . . . . . ... . . 597 

Acute Hydrocephalus . . . . . . . . 600 

Chronic Hydrocephalus . . . . . . .602 

Congenital Hydrocephalus ........ 603 

Tubercular Meningitis . . . . . . . . 605 

Acute Meningitis . . . . . . . . . 609 

Chronic Meningitis . . . . . . . . 612 

Abscess of the Brain . . . . . . . . 613 

Intra-cranial Tumors . . . . . . . . 617 

Aphasia .......... 623 

Vertigo ......... 626 

Diseases op the Medulla Oblongata ...... 632 

Haemorrhage in the Medulla ....... 632 

Occlusion of the Vessels of the Medulla . . . . . .634 

Acute Inflammation of the Medulla (Acute Bulbar Paralysis) . . . 634 

Chronic Inflammation of the Medulla (Chronic Progressive Bulbar Paralysis) 635 

Diseases of the Spinal Meninges and Cord ..... 639 

Hyperaemia of the Spinal Cord ...... 639 

Spinal Meningeal Haemorrhage ....... 641 

Pachymeningitis Spinalis ....... 643 

Spinal Meningitis ......... 644 

Acute Myelitis ......... 648 

Chronic Myelitis ......... 652 

Posterior Spinal Sclerosis (Progressive Locomotor Ataxia) . . . 655 

Lateral Spinal Sclerosis (Spastic Spinal Paralysis) . . . . 662 

Infantile Paralysis ........ 664 

Progressive Muscular Atrophy ....... 668 

Pseudo-Hypertrophic ....... 672 

Chronic Poliomyelitis Anterior . . . . . . .673 

Acute Ascending Paralysis ....... 675 

Multiple Sclerosis of the Brain and Cord ...... 677 

Dementia Paralytica ........ 681 

Syphilis of the Nervous System ....... 686 

Cerebral SyphiHs ........ 686 

Spinal Syphilis ........ 689 

Syphilis of the Nerves . . . . . . 691 

Cerebro-spinal Neuroses . . . . . . . .691 

Epilepsy . . . . . . . , .691 

Hysteria .......... 699 

Neurasthenia . . . . . . . . . 707 

Catalepsy .......... 712 

Paralysis Agitans . . , . . . . . 713 

Chorea . . . . . . . . . . 716 

Writer's Cramp . . . . . . . . 719 

Tetanus . . . . . . . . . .721 

Diseases of the Peripheral Nerves ...... 725 

Neuritis .......... 725 



xxii 



CONTENTS. 



PAGE 

Progressive Multiple Neuritis . . . , » . . 72*7 

Atrophy of the Nerves . . . ' . » . . . 729 

Neuralgia ......... 729 

Tic-Douloureux . , . . . . . . 729 

Cervico-occipital ........ 733 

Cervico-brachial ........ 733 

Intercostal ........ 733 

Lumbo-abdominal ........ 733 

Sciatica . . . ... . , . 734 

Convulsive Tic (Histrionic Spasm) ....... 738 

Torticollis (Wryneck) . . . . . . . .739 

Spasm of the Diaphragm (Singultus) . . . . . .741 

Paralysis of the Ocular Muscles . . . . . . 741 

Facial Paralysis . . . . . . . . .. 743 

Vaso-motor and Trophic Neuroses ...... 745 

Hemicrania (Migraine) ........ 745 

Angina Pectoris ........ 747 

Exophthalmic Goitre (Graves's Disease) . . . . . .749 

Myxoedema . . . \ . . . . . 752 

GENERAL OR CONSTITUTIONAL DISEASES. 

Eruptive Fevers ......... 755 

Variola . . . . . . . . . .755 

Confluens . . . . . . . . . 763 

Hsemorrhagica ........ 764 

Varioloid ......... 765 

Vaccinia and Vaccination . . . . . . • • 768 

Varicella ......... 771 

Rubeola (Measles) . . . '7V2 

Roseola (Roetheln) . . '^'78 

Scarlatina— Scarlet Fever ........ 779 

Diagnosis of the Eruptive Fevers . . . • . . 789 
Erysipelas 

Fevers . . . • • . - . . . . '?95 

Typhoid Fever '795 

Typho-Malarial Fever . . . . . • • • 810 

Typhus Fever . . . . • • • • • 812 

Relapsing Fever . . . . . • . • 817 

Yellow Fever 822 

Dengue. . . . . • • • • • 831 

Heat-Fever. ......... 834 

Miasmatic Diseases 838 

Cholera 838 

Diphtheria 847 

Cerebro-spinal Meningitis ....... 862 

Influenza (Epidemic Catarrh) 872 

Hay-Fever (Summer Catarrh) 875 

Whooping-Cough (Pertussis) ....... 879 

Parotiditis (Mmnps) 882 

Malarial Diseases ........ 885 

Intermittent and Remittent Fevers ...... 885 



CONTEXTS. 



xxiii 



PAGE 



Disorders of Xuteition . , . . . « . .901 
Scrofula ...... o ... 901 

Acute Miliary Tuberculosis ....... 906 

Eickets .' '. . . .909 

Lymphadenoma . . . . . . . . 915 

Acute Rheumatism ........ 920 

Chronic Rheumatism ........ 928 

Gout (Podagra) . . . . . . . . .930 

Arthritis Deformans ........ 936 

Diabetes ilellitus ......... 939 

Diabetes Insipidus ........ 948 

Alcoholism ......... 950 

Amyloid Disease . . . . . ... 960 

Animal Poisons .......... 966 

Hydrophobia ......... 966 

Parasites . . . . . . . . . . 970 

Trichinae and Trichinosis . . . . . . . 970 

Chyluria . . .... . . . . .975 

Disease-producing ilicroscopic Organisms ..... 978 



LIST OF ILLUSTEATIOI^S. 



FIG. PAGE 

1. Thoracic and Abdominal Regions (Anterior) ..... 1 

2. Thoracic and Abdominal Regions (Posterior) .... 4 

3. Torsion of the Intestine . . . . . . . .121 

4. Constriction of the Intestine by a Band of False Membrane . . 121 

5. Taenia Solium ......... 133 

6. Scolex of Taenia ........ 133 

7. Bothriocephalus Latus . . . . . . . .133 

8. Bothriocephalus Latus, Egg of . . . . . . 133 

9. Bothriocephalus Latus, Scolex of . . . . . .134 

10. Ascaris Lumbricoides . . . . . . . 138 

11. Trichocephalus Dispar . . . . . . . .141 

12. Oxyurus Yermicularis ....... 141 

13. Horizontal Section of Thorax, Abdomen, and Pelvis . . . ,161 

14. Area of Hepatic Dullness in Cancer of the Liver . . . . 201 

15. Scolex of Taenia Echinococcus . . . . . . . 204 

16. Taenia Echinococcus of the Pig ...... 204 

17. Taenia Echinococcus of the Dog ....... 204 

18. Enlargement of the Liver by Hydatids ..... 205 

19. Relation of the Yalves and Orifices of the Heart to the Ribs, Sternum, and Exterior 270 

20. Posterior View of Thorax . . . . . . .271 

21. Effusion into the Sac of the Pericardium . . . . . 278 

22. Sphygmographic Tracing in Hypertrophy of the Heart .... 296 

23. Sphygmographic Tracing in Aortic Stenosis . . . . .314 

24. Sphygmographic Tracing in Aortic Insufficiency . . . .315 

25. Sphygmographic Tracing in Mitral Stenosis . . . . .318 

26. Sphygmographic Tracing in Mitral Insufficiency . . . .319 

27. Pleurisy with Effusion . . . . . . . 362 

28. Hydropneumothorax ........ 373 

29. Fibrous Tissue in Sputa ..... . . 381 

30. Temperature Range in Pneumonia (Crisis) . . . . . . 384 

31. Temperature Range in Pneumonia (Lysis) ..... 385 

32. Caseous Pneumonia . . . . . ... 404 

33. Temperature Range in Caseous Pneumonia ..... 406 

34. Miliary Tuberculosis ........ 407 

35. Fragment of Lung-Tissue and Sputa . . . . . 415 

36. Cavities; one partly filled, one empty ...... 419 

37. Casts in Acute Parenchymatous Nephritis ..... 520 



xxvi 



ILLUSTRATIONS. 



FIG. 

38. Epithelium from Convoluted Tubes 

39. Casts in Chronic Parenchymatous Nephritis 

40. Casts becoming fatty .... 

41. Hyaline Casts .... 

42. Various Forms in Pyelitis 

43. Various Forms in Urinary Deposits . 

No. 1. Uric Acid. 

2. Urate of Soda. 

3. Cystine. 

4. Oxalate of Lime. 

5. Dumb-bell Oxalate of Lime. 

44. Epithelium of the Kidney 

No. 1. Of the Ureter, 
2. Of the Urethra. 

45. ^sthesiometer .... 

46. Dynamometer ..... 

47. Dynamograph .... 

48. Temperature in Discrete Variola 

49. Temperature in Coherent Variola 

50. Temperature in Confluent Variola 

51. Temperature in Uncomplicated Measles 

52. Temperature in Measles with Catarrhal Pneumonia 

53. Temperature in Typhoid Fever 

54. Temperature in Acute Miliary Tuberculosis 



SPECIAL PATHOLOGY AND THERAPEUTICS, 

LOCAL DLS EASES, 



DISEASES OF THE DIGESTIVE SYSTEM. 



TOPOGRAPHY OF THE ABDOMEN: PHYSICAL EXPLORATION. 



Regions. — In Figs. 1 and 2 the topography of the abdomen is 
indicated, according to the usually accepted arrangement. The posi- 
tion of the organs within, relative- 
ly to the exterior boundaries of re- 
gions, must be definitively known, 
to make the topographical outlines 
available for any useful purpose. 

In the epigastrium (4, Fig. 1) 
is contained the left lobe of the 
liver, the pyloric end of the stom- 
ach, the first part of the abdominal 
aorta, the semilunar ganglion and 
the solar plexus, the pancreas, a 
part of the transverse colon, the 
supra-renal bodies, and a portion 
of each kidney. In the right hy- 
pochondrium, we find the liver, 
gall-bladder, portal vein, the vena 
cava, the hepatic artery, hepatic 
and common ducts, the hepatic 
plexus, the ascending colon, the 
duodenum, kidney, etc. ; and in 
the left, the stomach, spleen, junc- 
tion of transverse with descending 
colon, kidney, etc. In the umbili- 
cal and lumbar regions, we find — 

beginning with the right — the ascending colon, the small intestines, 
the vena cava, the aorta, the ureters, the mesentery, the splanchnic 
3 




Fig. 1. — Thoeacic and Abdominal Ee- 
GioNs. Anterior. — 1, Sternal ; 2, Sub- 
clavicular ; 3, Mammary ; 4, Epigastric ; 
5, Hypochondriac ; 6, Umbilical ; 7, 
Lumbar ; 8, Hypogastric ; 9, Iliac. Af- 
ter Eiidinger. 



2 



DISEASES OF THE DIGESTIVE SYSTEM. 



nerves, the kidneys, the descending colon, etc. In the right iliac 
region are contained the caecum, the appendix vermiformis, the iliac 
arteries and veins, etc. In the hypogastriiira are placed the bladder, 
the nreters, iliac arteries and veins, etc., and in the left iliac region 
the sigmoid flexure of the colon. 

Inspection, palpation, and percussion are the chief physical modes of 
obtaining information of the state of the organs composing the digestive 
system, but occasionally auscultation may also be employed. Inspec- 
tion discovers the state of the mucous membrane of the lips, cheeks, 
tongue, tonsils, palate, and pharynx. Inspection by rhinoscopy dis- 
closes the condition of the vault of the pharynx, of the posterior 
nares, and of the orifices of the Eustachian tubes — by laryngoscopy, 
of the epiglottis, the larynx, and upper trachea. For ordinary pur- 
poses an inspection of the throat may be made without the aid of a 
special illuminating apparatus. The patient is seated opposite the win- 
dow, the mouth is widely opened, and the tongue is gently steadied 
by the depressor, handle of a spoon, etc. ; now, a deep inspiration is 
taken, and all parts of the throat, except, of course, the posterior nares 
and larynx, are well brought into view. Violent attempts to depress 
and hold the tongue only defeat their object by exciting reflex at- 
tempts to swallow or regurgitate. 

When the abdomen is to be examined, the patient should usually 
be recumbent, the shoulders somewhat elevated, the thighs flexed on 
the pelvis, and the abdominal muscles relaxed by the voluntary efforts, 
as far as may be. Examination should be made in the erect position 
also. It is a useful expedient to outline the regions with a soft pencil, 
and to indicate by the same means the changes in sonority discovered 
on percussion. 

Inspection. — On iyispection of the abdomen the following facts may 
be learned : changes in the color of the skin, and the position of abnor- 
mal pigment deposits ; prominence or retraction of the walls ; move- 
ments inbreathing (thoracic breathing, abdominal), drawing in during 
inspiration, instead of outward expansion, jerking or rhythmical respi- 
ration ; the state of the veins when unduly prominent ; exaggerated 
epigastric pulsations, and presence of abnormal pulsations ; distention 
of the whole abdomen, and undue prominence in particular situations, 
as in the epigastrium when the stoniach is too full, local swellings due 
to gas, accumulated faeces, enlargement of organs, etc. 

Palpation and Percussion. — To the sense of touch in health, the 
abdomen makes the impression of a soft, flexible, and dough-like 
material, except where the rectus muscle imparts the sensation of com- 
bined firmness and resistance. "When the cutaneous reflex is height- 
ened from any cause, or peritonitis exists, the rectus contracting in 
segments — as it may do — the impression made on the sense of touch 
may be very confusing. 



TOPOGRAPHY OF THE ABDOMEN. 



3 



By palpation we recognize the existence of tender or painful 
points, enlargement or induration, or changes in the contour of or- 
gans, tumors, fecal accumulations, and floating or movable organs. 
As, however, the application of palpation to the study of the condi- 
tion of the abdominal organs will, necessarily, be referred to in con- 
nection with their diseases, only some general practical suggestions 
will be made here. 

On palpation and percussion of the stomach, the amount of its con- 
tents, the area occupied by the organ, the existence of tumors — except 
those at the cardiac orifice — may be made out. It should not be for- 
gotten that usually, but not invariably, the left lobe of the liver extends 
across the epigastrium and downward to a varying extent, and that the 
greater part of the stomach lies under the ribs in the left hypochon- 
drium. The position of the pylorus is not constant. The stomach 
may, indeed, have a nearly vertical position, and the pylorus extend to, 
and even reach below, the umbilicus. This is the more apt to happen 
when the pylorus is weighted by a tumor, which may, in consequence, 
seem to be attached to some other organ distant from the stomach. 

The pulsations of the abdominal aorta in thin subjects, and when 
abnormally strong, may be readily felt, especially in those persons 
affected by a depressed state of the sympathetic system. A tumor 
overlying the abdominal aorta may have a pulsation communicated to 
it that is not easily distinguished from the pulsations of an aneurism. 

In the normal state of that organ, the spleen can not be felt, or 
defined by percussion with certainty, but when enlarged, especially on 
a full inspiration, its size and condition may be made out. In doubt- 
ful cases, percussion should be practiced when, the patient taking a 
full inspiration, the spleen is forced down into a position where the 
area of dullness can be ascertained. When the stomach is enlarged 
and distended with gases, the left hypochondrium becomes resonant, 
the percussion note having a highly tympanitic quality. If the spleen 
be enlarged, and especially if large enough to fill out the space be- 
neath the ribs, the percussion note will be dull or flat. By the char- 
acter of the percussion-sounds, the dimensions of the stomach can be 
approximated, in cases of dilatation of the organ. 

A distended state of the transverse colon modifies, proportionally, 
the hypochondriac and epigastric regions ; by palpation and percussion 
it can be ascertained whether the increased dimensions of the bowel 
be due to faeces or gas, or to both. Impaction occurs, greatly more 
frequentty, in the caecum, and at the sigmoid flexure, than elsewhere 
in the large intestine. In some comparatively infrequent instances, 
the transverse colon has a Y-shape, and the apex of the Y extends 
below the umbilicus — a condition of things productive, it may be, of 
serious consequences, by favoring obstruction, and confusing the diag- 
nosis, by modifying palpation and percussion. 



4 



DISEASES OF THE DIGESTIVE SYSTEM. 



Auscultation. — Auscultation is of far less importance as a means of 
ascertaining the state of the abdominal organs than inspection and per- 
cussion ; nevertheless, it may be indispensable. Thus, to diagnosticate 

aneurism of the aorta, auscul- 
tation becomes essential. Only 
in this way can a pulsating tu- 
mor be differentiated from an 
aneurism. 

Although narrowing of the 
pyloric orifice may not be diag- 
nosticated by auscultation, yet 
by careful observation a differ- 
ence may be detected between 
the sound caused by the pass- 
age of gas through the natural 
pyloric orifice, and that which 
is produced by a narrowed out- 
let. To ascertain this, the steth- 
oscope is placed over the pylo- 
rus, and then the stomach is 
forcibly pressed upon to drive 
the gas and liquid through into 
the duodenum. The character 
of the resulting sound varies 
with the size of the orifice, and 
hence the laws of acoustics en- 
able us to approximate, at least, 
to the degree of stenosis. 

In Fig. 2 the regions of the 
body on its posterior aspect are 
given. In the subscapular re- 
gions of the right and left sides are contained the organs noted as 
occupying the hypochondriac regions in front. The renal and lumbar 
regions contain the ascending and descending colon respectively, the 
kidneys, the abdominal aorta, and the vena cava, the ureters, the small 
intestines, etc. 

STOMATITIS. 

Deflnltioil. — Stomatitis is an inflammation of the buccal mucous 
membrane. There are various forms of the disease, determined by 
the seat and character of the lesion — for example : simple, follicular 
or aphthous, ulcerative, mercurial, and parasitic. 

Causes. — Simple stomatitis may be a part of a catarrhal process 
which involves the mouth, the oesophagus, and the stomach ; but more 




STOMATITIS. 



5 



frequently it is caused by local irritants, sucli as condiments, tobacco, 
too hot and too cold liquids, etc. The follicular or aphthous form 
occurs at all ages, but is more common in early life. Children having 
feeble constitutions depressed by bad hygienic influences are especially 
liable. Often dependent on gastro-intestinal disorders, it is a frequent 
complication of prolonged diarrhoea, and more certainly so when the 
stools have an acid reaction. The ulcerative form is due to all those 
causes, also, which depress the vital forces — to fatigue, to excesses of 
all kinds, to bad hygiene, to damp and dark habitations, to improper 
and insufficient food, and to various cachexias. Mercurial stomatitis is 
produced by the systemic action of mercury, in what form or mode 
soever the metal may be introduced into the organism. It should be 
remembered that in infancy the mercurial action does not manifest 
itself in stomatitis, but in an equally injurious toxic action in another 
form. 

Symptoms. — It is almost invariably true of inflammation of a mucous 
membrane, that the first effect of the process is to arrest secretion of its 
glandular appendages. The membrane becomes rough and swollen, and 
of a more or less vivid red color ; and the glands, especially those at 
the base of the tongue, by an increase of their contents, enlarge and 
become prominent ; but the dryness, in a few hours, is succeeded by 
increased secretion. The fluid now poured out from the surface of the 
mucous membrane consists of a transparent solution — serum — holding 
in suspension numberless young cells, cast-off epithelium undergoing 
fatty metamorphosis, and minute organisms, bacteria, etc., derived 
from the external air. The exuded fluid t^nds to accumulate at cer- 
tain points in the cheeks and on the gums, and on the floor of the 
mouth. In some places, especially at the mouths of the follicles, 
superficial erosions are produced by the falling off of the epithelium. 

The mouth feels dry and hot at the outset. Considerable pain is 
experienced at every movement of the lips, tongue, and soft palate, or 
when hot and cold liquids or irritating solids are introduced into the 
mouth. Taste is much perverted, or is entirely wanting. The secre- 
tion poured out in the mouth excites a subjective taste of foulness, and 
this is represented, objectively, by an odor of putrefaction, especially 
when there are carious teeth. 

The characteristic of the aphthous form of stomatitis is a fibrinous 
exudation occurring first in the follicles. The exudation has a gray- 
ish or yellowish-white tint, round or oval in shape, and varying in size 
from the head of a pin to a bean. Subsequently, additions laterally of 
fibrin bring the isolated deposits in contact, and thus larger patches 
are produced. The exudation softens in two or three days, the mucous 
membrane disintegrates, and small ulcers are formed, which cicatrize 
in a week or two. As a similar process takes place in the skin, in 
variola, the same terras are used to describe the variations in the aph- 



6 



DISEASES OF THE DIGESTIVE SYSTEM. 



thous patches ; thus they are said to be discrete, coherent, confluent, 
etc. In infancy the aphthous exudation is arranged somewhat sym- 
metrically, on the veil of the palate, and at the junction of the veil 
with the bony vault ; in adults, the exudation occurring in the follicles 
assumes a vesicular and pustular character, and attacks the lips, the 
cheeks, and the point of the tongue. 

Considerable suffering attends aphthous stomatitis ; the mouth is 
dry with the initial hypersemia ; but, in a short time, a transparent 
and viscid secretion streams from the cavity ; the ulcers, painful at all 
times, are exquisitely so when acids, sweets, and sapid substances are 
ingested, and by the mere movements of the jaws in mastication. The 
breath is fetid ; the sublingual, submaxillary, and parotid glands be- 
come swollen and sensitive to pressure. The system at large sym- 
pathizes with the local disturbance ; and, in children especially, there 
is more or less fever ; disturbances of the digestive organs ensue ; the 
urine becomes scanty and high-colored. It occasionally happens that 
systemic infection takes place, with all the evidences of the most 
profound adynamia — the so-called typhoid state. Gangrene of the 
mucous membrane may then set in, or it may commence in the mouth, 
inducing an adynamic state. More frequently, aphthae occur in the 
mouth as a complication in typhoid or puerperal fever, when gangrene 
of the mucous membrane may follow. 

Muguet is a term applied by the French to designate a form of 
exudative stomatitis, the special characteristic of which is the occur- 
rence of minute parasitic organisms. The local morbid process is the 
same as in the other forms of stomatitis : hyperaemia, arrest of, followed 
by greatly increased secretion ; production of new cells and casting off 
of the epithelium, but without exudation of fibrin. The buccal secre- 
tion is usually acid, a condition which favors the growth of parasitic 
organisms. Atmosj)heric germs are deposited, and a process of acid 
fermentation goes on with a correlative growth of microscopic organ- 
isms. Whitish masses, looking like curds, are to be seen on the pal- 
ate, cheeks, tongue, and lips. These masses may remain separate and 
discrete, or enlarge, cohere, and cover the whole mucous surface. 
They may also extend into the air-passages, but more frequently into 
and through the intestinal canal. The extension into the latter organs 
is not by growth along contiguous surfaces, but by deglutition. In 
the fauces these curd-like masses interfere with deglutition ; in the 
larynx with respiration. 

The membrane-like exudation of muguet is not truly a membrane, 
but is a collection of epithelial and mucous corpuscles matted to a 
mass by the vegetation of oidium albicans. The systemic disturbance 
produced by it depends on the extent of the patches : if small in size 
and discrete, there may be no fever and only restlessness due to the 
soreness of the mouth ; if confluent, there may be considerable fever. 



STOMATITIS. 



7 



When patches develop in the intestinal canal after the vegetations 
are swallowed, very decided gastro-intestinal symptoms may be pro- 
duced. There will be more or less diarrhoea, or the stomach may be- 
come excessively irritable, food being rejected as soon as swallowed. 
The suspension of or serious interruption in the process of alimenta- 
tion causes an extreme degree of anaemia and impairment of the vital 
forces wdth cerebral symptoms, comprehended under the term hydren- 
cephaloid, or spurious hydrocephalus. These cerebral symptoms are 
frequently confounded with the opposite state — cerebral congestion. 

Diagnosis. — The ulcerated form of stomatitis is to be distinguished 
from syphilitic raucous patches. The distinction rests on the history, 
the form and duration of the patches, and the presence of concomi- 
tant symptoms. In syphilis the ulcers are less sharply defined and 
contain ashy-gray sloughs closely attached ; they are slow to heal, and 
appear and disappear ; they are accompanied by other syphilitic 
lesions, and preceded by a characteristic symptomatology. 

The aphthous form of stomatitis, muguet, may be confounded with 
diphtheria. The differentiation is arrived at by attention to the fol- 
lowing points : In diphtheria the exudation usually begins as a delicate 
pellicle on the tonsils or veil of the palate ; in muguet as a curd-like 
or pultaceous mass, on the lips, gums, or cheeks — the former extend- 
ing forward, the latter backward. The exudation of diphtheria thick- 
ens and widens as it develops, and extends into the Eustachian tube, 
nares, larynx, and to wounded surfaces ; that of muguet is rarely 
coherent, and extends into the fauces and oesophagus. The exudation 
of muguet is made up of cast-off epithelium, mucous corpuscles, and 
the vegetation of oidium albicans ; that of dipththeria, of a true 
fibrinous material within and upon the epithelium, and an immense 
quantity of bacteria, which also extend into the neighboring vessels 
and lymphatics. The odor, the swelling of the cervical lymphatics, 
the general systemic infection, and the profound adynamia, together 
with the peculiar sequelae of diphtheria, separate this malady readily 
from aphthous stomatitis. 

Treatment. — Attention to diet is of the first importance. Acid 
substances, sweets, and condiments, excite smarting and distress in the 
process of mastication. In adults ulcerative stomatitis is often due to 
errors of diet, and such subjects soon learn that acid fruits and vegeta- 
bles, and those capable of acid indigestion in the stomach, wnll produce 
a plentiful crop of painful ulcers in the mouth. Obviously, in such 
cases, the offending articles should be omitted from the diet. The 
starchy and saccharine substances, owing to their facility for undergo- 
ing the acid fermentation, may be equally objectionable. In infants, 
to avoid the evil effects of acid indigestion, some sodic bicarbonate, or 
lime-water, is added to the milk. In ulcerative stomatitis, local appli- 



8 



DISEASES OF THE DIGESTIVE SYSTEM. 



cations are highly serviceable. The surface of each ulcer should be 
cleansed and a little pure carbolic acid applied. This produces a 
momentary smarting, but great relief follows. A crystal of sul- 
phate of copper, or nitrate-of-silver stick, may be used to touch the 
surface of the ulcers — to set up a new action in the diseased part. If 
the local disease be due to gastric disorder, besides regulation of the 
diet, remedies to allay gastric irritability are necessary : for example, 
bismuth, oxide of silver. Fowler's solution of arsenic, hydrocyanic 
acid, etc. In some cases remarkably good results follow the admin- 
istration of potassium chlorate in large doses — for adults fifteen grains 
every four hours, and for children proj)ortionately. In aphthous stoma- 
titis the same principles of treatment obtain ; but some attention must 
be given to the peculiar local conditions. As the extension of the 
patches is determined, to a large extent, by the growth of the oidium 
albicans, remedies destructive of minute organisms ought to be em- 
ployed — as salicylic acid, dissolved by aid of sodium biborate ; quinine 
sulphate, in solutions of varying strength according to the age of the 
subject ; carbolic and boracic acid solutions, etc. The internal admin- 
istration of quinine and salicylic acid, to arrest the spread of the vegeta- 
tions swallowed, is highly important. A combination of bismuth and 
carbolic acid is very effective to relieve the extreme irritability of the 
stomach. Potassium chlorate is equally effective in this as in the 
ulcerative form. To be successful, it is necessary to administer large 
doses. Mercurials should never be given in any form, for the destruc- 
tive ulcerations and the gangrene, which now and then occur, will be 
attributed to their action. 

Mercurial stomatitis will require the same general plan of treat- 
ment as the other forms of the disease, with the exception that elimi- 
nation of the poison must be promoted by the administration of the 
iodide of potassium. 



GLOSSITIS. 

Definition. — Glossitis is a term that signifies inflammation of the 
tongue. As usually one half of the organ is involved, the malady is 
sometimes designated hemi-glossitis. "When confined to the mucous 
membrane, it may be entitled superficial or mucous glossitis. When| 
the substance of the tongue is attacked, the disease may be called 
interstitial or parenchymatous glossitis, according as the interstitial 
connective tissue or the muscular is the seat of the morbid process. 

Causes. — Mucous glossitis is usually caused by the contact of steam, 
hot liquids, chemical irritants, etc. It may, also, be due to an exten- 
sion by contiguity of tissue, of stomatitis, and thus constitute a part 
of a general inflammation of the mucous membrane of the oral cavity. 



GLOSSITIS. 



9 



It is usually a secondary disease, arising in the course of various septic 
maladies, just as parotitis does, which is a more common affection. 
Among the infectious diseases, of which glossitis may occur as a com- 
plication, are erysipelas, pyaemia, puerperal diseases, typhoid fever, etc. 
Prof. B. Ball maintains that hemiglossitis is a neurosis. 

Pathological Anatomy. — In mucous glossitis the anatomical changes 
are limited to the mucous membrane, and consist in hypersemia, red- 
ness, and swelling, and the epithelium becomes cloudy, granular, and 
is detached. Especially along the borders of the tongue, and on its 
dorsal surface, are these changes most pronounced, giving a raw, red, 
and somewhat glazed appearance to these parts of the organ. In 
papilliform glossitis the large papillae of the base of the tongue are 
swollen by hyperaemia and an accumulation of their contents. 

In the deep-seated or parenchymatous glossitis, one half of the 
tongue is usually involved at the outset. The inflammatory process is 
thus limited, because of the arrangement of the vessels and the attach- 
ment of the muscles along the central tendinous raphe, which opposes 
a barrier to the extension of the inflammation in this direction. The 
whole tongue may ultimately become engaged, and is invaded in the 
more formidable cases. The mucous membrane is swollen, deeply 
injected, softened, its epithelium detached by a fibrinous exudation. 
An interstitial exudation separates the muscular elements, which are 
affected by a granular degeneration in which their striae disappear ; 
they soften, are completely disassociated, and are finally broken up 
into a diffluent mass. The interstitial connective tissue, also, partici- 
pates in the inflammation, the cellular elements undergo multiplica- 
tion, and, with the wandering leucocytes, form foci of suppuration, 
which, finally coalescing, constitute a large, purulent collection. The 
largest accumulation of pus may be at the base of the tongue, and 
purulent infiltration of the glotto-epiglottic folds may take place. In 
the subacute form of interstitial glossitis, a hyperplasia of the con- 
nective tissue occurs, forming patches of sclerosis ; and in the chronic 
form the new tissue encroaches on the muscular, causing atrophy and 
degeneration, so that the tongue, or one half, or a smaller portion of 
it, will be injured and deformed. 

Symptoms. — In superficial glossitis there are constantly present a 
decided heat and irritation of the tongue, and the sense of taste is im- 
paired or lost. Actual pain and an intolerable smarting and burning 
are experienced in the attempt to masticate, especially if the substance 
taken into the mouth is acid or pungent. The saliva flows abundantly, 
and is rather viscid. The sublingual glands appear swollen, and are 
somewhat tender. The movements of the tongue in speech and deg- 
lutition as well as in mastication are painful. The organ is red, raw- 
looking, sometimes smooth and glazed ; the papillae, in general, are 



10 



DISEASES OF THE DIGESTIVE SYSTEM. 



swollen and prominent, especially the circumvallate. In the papilli- 
form glossitis these bodies are much swollen, and are very promi- 
nent objects, while the rest of the organ presents a normal appear- 
ance. Some heat is experienced in them, and in the act of swallow- 
ing they are ^^ainful. Very often they cause a feeling of a foreign 
body lodged on the base of the tongue, and excite repeated efforts of 
swallowing. 

Very different are the symptoms when the body of the tongue is 
involved in the inflammatory process. The organ enlarges and may 
become enormous — too large, indeed, for the mouth — and protrudes be- 
tween the teeth. The swelling, beginning usually on one side, quickly 
extends to the other, so that ultimately the site of the original mis- 
chief is lost in the general tumefaction. Especially does the base of 
the tongue enlarge, pressing strongly against the roof of the mouth, 
and, pushing the soft palate into the fauces, forces the epiglottis down 
on the larynx. With the first swelling the movements of the tongue 
become stiff and constrained, speech guttural and thick, and swallowing 
difficult and painful ; but when the fauces and larynx are obstructed, 
swallowing is impossible, speech unintelligible, and even breathing 
grows more and more difficult. Very great pain in the tongue, 
throat, and ears, is now experienced ; a tough and rather acrid saliva 
flows from the mouth incessantly ; the lymphatic glands of the neck 
are swollen, often immensely so, and fill out the whole space from the 
chin to the sternum ; the face is puffy and cyanosed, partly in conse- 
quence of the swelling of the cervical glands preventing the return 
of blood through the jugulars, and partly because the swollen tongue 
hinders the passage of air into the larynx. So rapid is the progress 
of the swelling that death may ensue in from twenty-four to forty- 
eight hours by suffocation, or an increasing stupor announces the onset 
of carbonic-acid poisoning. The usual constitutional symptoms are 
present. A more or less decided chill inaugurates the febrile move- 
ment ; the pulse rises in an adult to 110, 120, or even 140 per minute, 
and the temperature to 102°, 103°, or in severe cases to 105° Fahr. ; 
the urine is scanty and acid in reaction, and the skin is dry. The 
tongue is deep red, dry, hot, and of a brawny hardness, except at some 
point where pus has formed and approaches the surface. At the 
point of maximum intensity, it may be, when suffocation seems im.mi- 
nent, the case may suddenly improve by the spontaneous evacuation 
of matter. Then the swelling subsides, the breathing becomes easier, 
a little liquid may be swallowed, and convalescence is soon established. 
More or less sloughing of the connective tissue, with consequent de- 
formity on cicatrization, may occur, and gangrene, very rarely. In 
some instances resolution takes place, the swelling slowly subsides 
from the maximum, and the general state improves correspondingly. 



GLOSSITIS. 



11 



When glossitis comes on in the course of an infectious disease, the 
swelling develops more slowly than when it is an idiopathic affection, 
gangrene is more apt to occur, and the general condition is extremely 
grave. 

Course, Duration, and Termination.— In the most acute cases life 
may be put in jeopardy by the swelling which prevents the access of 
air in so short a time as twenty-four hours. Chills and high fever — 
the temperature rising to 104°, 105°, or 106° Fahr. — and sweats will 
indicate the occurrence of suppuration. Increased difficulty of breath- 
ing may be due to an extension of the suppuration, the pus dissecting 
from the base of the tongue under the glotto-epiglottidean folds, and 
even to the aryteno-epiglottidean. Spontaneous rupture or an incision 
permitting escape of matter will afford prompt relief. When resolu- 
tion takes place without suppuration, the improvement, if it occur, is 
slow, and the swelling subsides by small degrees from day to day. 
When glossitis comes on in the course of an infectious malady, which 
has already taxed the powers of life to their utmost, the additional 
disease will usually soon determine a fatal result. Sudden death may 
be produced by an oedema of the glottis, from rupture of an abscess 
into some of the great vessels, or from paralysis of the heart. The 
disease may continue several weeks, resolution slowly taking place ; 
or, an abscess discharging favorably, speedy recovery will ensue ; or 
more or less sloughing and loss of substance may occur, a tedious 
convalescence follow, and the tongue remain impaired in its func- 
tions. 

Diagnosis. — Glossitis will not be confounded with any other mal- 
ady, since every step in its development can be watched. Gumma of 
the tongue may cause some enlargement, but its progress is slow, and 
is not accompanied by the systemic symptoms of glossitis, and is ac- 
companied by the usual syphilitic manifestations. Hypertrophy of the 
tongue may be confounded with chronic interstitial glossitis, but the 
distinction is made by reference to the course of the latter, which leads 
to induration, usually in patches, and to atrophy of the muscular ele- 
ments. Secondary swelling of the tongue may result from obstruction 
to the salivary duct by a calculus, and from inflammation of the sub- 
lingual glands. The history of the case and attention to the order in 
which the parts swelled, the discovery of a salivary calculus in position, 
and the condition of the tongue, ought to render the differentiation 
comparatively easy. 

Treatment. — The superficial form of glossitis requires the same 
remedies as stomatitis, or it may be safely permitted to pursue its 
natural course, a suitable regimen being enforced. The deep-seated 
form requires more energetic handling. When there is much sthenic 
reaction, the subject being vigorous, leeches should be applied under 



12 



DISEASES OF THE DIGESTIVE SYSTEM. 



the angles of the jaws, or free scarifications of the tongue should be 
practiced. Water, as hot as can be borne, should be held in the mouth 
as long and as frequently as possible ; or ice may be as freely used, if 
grateful or more beneficial to the patient. Deep incisions may be 
necessary to evacuate matter, or if swelling threatens the life by as- 
phyxia. Tracheotomy may be required in an extreme case. If swal- 
lowing be prevented by the swelling, a flexible tube can be passed into 
the oesophagus through the nares, and nutritive liquids be thus con- 
veyed into the stomach. Support by suitable aliment is required from 
the beginning, and the use of alcoholic stimulants must be resorted to 
as soon as the powers of life flag. At the beginning, if there be much 
reaction, the arterial sedatives — aconite, digitalis, veratrum viride — 
may be employed ; but usually, quinine is more efficient as an apyretic, 
and to check the formation of pus. At the outset, fifteen to twenty 
grains of quinine and half a grain of morphine should be given to an 
adult, and subsequently from three to five grains of quinine and one 
eighth of morphine, every four hours. If swallowing become difficult, 
the remedies can be administered in solution by enema, the morphine 
being suspended if there be any indications of stupor from carbonic- 
acid poisoning. 

TONSILLITIS. 

Definition. — By t07isillUis, it is intended to express an inflamma- 
tion of the tonsil. Quinsy is commonly used to signify the same dis- 
ease. Under the term tonsillitis are, however, included several dis- 
tinct morbid states. Interstitial tonsillitis signifies an inflammation 
of the connective tissue of the organ ; peritonsillitis, of the subjacent 
connective tissue ; and follicular tonsillitis, of the crypts or follicles. 
The first two are apt to cause suppuration — the last named, to cause 
ulceration. 

Causes. — A relationship has been supposed to exist between the 
ovaries and tonsils, but it is by no means well defined. Dr. James 
(London) first mentioned the coincidence of ovarian irritation with 
inflammation of the tonsils ; afterward. Dr. Echeverria, of New York, 
made the same statement ; and recently. Dr. Penrose, of Philadel- 
phia, has connected impotence with the ablation of the tonsils. The 
strumous diathesis and heredity are important factors in the etiology. 
Those having chronic hypertrophy are peculiarly liable to acute at- 
tacks terminating in suppuration. Such are predisposing causes. 
The most usual exciting causes are climatic changes — exposure to 
draughts of cold air, the body in a heated and perspiring state, sud- 
den variations in temperature, etc. Follicular tonsillitis with ulcera- 
tion — ulcerated sore throat — is usually preceded by disorders of diges- 



TONSILLITIS. 



13 



tion, and is apparently dependent on such derangements for its origin. 
An individual susceptibility to attacks undoubtedly exists, and those 
who have had them are more liable. Such subjects have seizures 
every winter, especially if the temperature changes are frequent and 
the atmosphere damp. Period in life is not without influence. Ton- 
sillitis is rare in infancy and in old age, and occurs most frequently 
from the second dentition to the thirtieth year. Both sexes are liable, 
and probably in an equal degree, although males are attacked more 
frequently because more exposed to the exciting causes. 

Pathological Anatomy. — The tonsils consist of a bunch of mucous 
follicles, held together by connective tissue, and are imbedded in a 
quantity of fatty and areolar tissue. A morbid process may affect 
the follicles or crypts, the interstitial tissue, or the subjacent tissue. 
In acute inflammation, there are intense hypersemia, redness and swell- 
ing of one or both tonsils, and of the palate and uvula. The swelling 
may be so considerable that the tonsils, meeting in the median line, 
press aside the pendulum and fill out the cavity of the pharynx. The 
secretion of the follicles consists of a soft, yellowish, puriform mate- 
rial, which is shown under the microscope to be composed of cast-off 
epithelium, mucus, and fatty detritus. The connective-tissue corpus- 
cles undergo proliferation, and abundant leucocytes, with some red 
corpuscles, float in the serum which fills the interstices. Multiplica- 
tion of the cellular elements finally is sufficient to constitute a purulent 
collection, which tends to external discharge by gradual softening of 
the superimposed tissues. When the inflammation occurs in the con- 
nective tissue beneath and around the tonsil, the same process takes 
place, the tonsil participates more or less in the hypersemia, but it is 
pushed upward and rather backward by the swelling beneath. When 
pus forms, it tends to burrow downward to the base of the tongue and 
under the corresponding pillar of the fauces, which is pushed forward. 
In the follicular form the hyperjemia is more especially exhibited in 
the network of vessels surrounding the follicles. The epithelium 
becomes cloudy from granular degeneration, and is detached. Disin- 
tegration of the basement membrane occurs, and thus an ulceration is 
established. The grayish slough, so long as it remains adherent, bears 
a superficial resemblance to a diphtheritic membrane, and the two pro- 
cesses are often confounded. 

Symptoms. — A feeling of general onalaise, aching of the back and 
limbs, and some chilliness, usually precede the local manifestations in 
the fauces. These are the well-known disturbances incident to " tak- 
ing cold." The ulcerative form of tonsillitis is preceded, as a rule, by 
stomachal distress, by indigestion, acid eructations, etc., and these 
symptoms are accompanied by an unaccountable languor and debility. 
The chilliness is followed by fever, which may consist in a very slight 



14 



DISEASES OF THE DIGESTIVE SYSTEM. 



elevation of the body-heat (99*5° to 100° Fahr.), or may attain to a 
more formidable reaction, the temperature rising to 102°, 103°, or even 
in children to 105° Fahr. Soon after the appearance of these consti- 
tutional symptoms, or coincidently with them, uneasiness is felt in tbe 
fauces — a sense of heat and irritation — and difficulty, with soreness, is 
experienced in swallowing. Tbese sensations increase and are con- 
stant, and meanwhile paroxysms of acute pain in the fauces, shooting 
through into the ear, occur spontaneously, or are excited by the effort 
to swallow. Frequent attempts to swallow are induced by the pres- 
ence in the fauces of a viscid mucus which constantly accumulates, 
and by the enlarging tonsils, which have the effect of an alimentary 
bolus ready to be grasped by the pharynx. When the attempt to 
swallow is made, the muscles of the face are contorted, strong efforts 
of the pharyngeal and cervical muscles are put forth, a burning sen- 
sation is felt in the fauces, together with an acute pain which pene- 
trates to the ear, tears come into the eyes, and, with a groan or cry, 
the act is finally accomplished, a part of the liquid it may be coming 
back through the nose. In the more severe cases, when both tonsils 
are affected, the act of deglutition becomes impossible, but usually 
the severe distress awakened by the effort prevents the attempt, which, 
if persevered in, may be accomplished in part. Instead of attempting 
to swallow, the patient tries, by frequent hawking and spitting, to 
clear the throat of the mucus which accumulates. The voice has a 
muffled, nasal tone, and words are with difficulty distinguished, or may 
indeed be entirely unintelligible. Hearing becomes dull, owing to the 
encroachment of the swollen tonsils on the Eustachian tubes, and 
noises of various kinds sound in the ears. The breathing is more fre- 
quent and less deep than in health, and may, indeed, become labored, 
inspiration being slow and difficult, if the swelling extend to the 
aryteno-epiglottic ligaments, or if oedema of the glottis should come 
on. If the lesions are confined to the tonsils, together with increased 
frequency and greater shallowness of breathing, there are usually par- 
oxysms of suffocative sensations of brief duration and purely subjective. 
On inspection, the fauces are seen to be red about the inflamed tonsil, 
or, if both are affected, the tonsils, palate, and uvula are red and swol- 
len, the redness terminating rather abruptly at the margin of the hard 
palate. The follicles are swollen. The tonsils, in the beginning of the 
inflammation, are deeply red, hypersemic, and prominent, their follicles 
containing a purulent-looking, semi-solid secretion, which may be mis- 
taken for a membranous exudation. As the swelling increases, the palate 
and the anterior pillars of the fauces are pushed forward, and the tonsils, 
if both are affected, meet in the median line. It is in the strumous sub- 
ject, and in the case of those who have had repeated attacks of the dis- 
ease, and have acquired a habit, as it were, that both tonsils are simul- 



TONSILLITIS. 



15 



taneously inflamed. Peritonsillitis, or inflammation of the subjacent 
connective tissue, is usually — invariably in my experience — unilateral. 
The swelling lies under and largely before the tonsil, and may be felt 
by the finger as a hard, brawny mass, extending to and embracing the 
corresponding portion of the base of the tongue. The tonsil, also, 
participates to some extent in the inflammation, but the formation of 
pus takes place in the adjacent tissue. This form of tonsillitis usually 
occurs in those who have suffered amputation of the tonsil. It is te- 
dious, painful, and sometimes dangerous to life, by the pus dissecting 
down beneath the aryteno-epiglottic folds, or by the sudden occurrence 
of oedema of the glottis. In cases of tonsillitis of any severity, the 
neighboring lymphatic glands enlarge, are tender, and the connective 
tissue about them becomes oedematous. In this way considerable swell- 
ing of the neck externally takes place ; when one tonsil only is affected, 
confined to the corresponding side, and, when both are attacked, the 
swelling is general. In this way it happens that the movements of 
the head and neck are constrained and painful. The tongue is usually 
heavily coated, and the breath fetid, especially in ulcerated tonsils. 
In this affection also, doubtless owing to the accompanying gastric 
derangement, there is much debility — out of proportion, certainly, to 
the local morbid process — and it is not attended by the sthenic reac- 
tion which accompanies the other form. 

Course, Duration, and Termination.— With the progress of the case 
much suffering is experienced. But little food or drink, sometimes 
none, can be taken during the time of maximum swelling, which may 
continue for two or three days. Rigors, not pronounced, or rather 
slight chilliness announce the suppuration. On inspection now, a change 
in the color of the swollen parts may be seen. Instead of a deep red- 
ness all over the inflamed area, there may be a circumscribed yellowish 
spot, at the summit of a prominence in the tonsil, or beneath the tonsil 
at the base of the anterior pillar of the fauces. Fluctuation may be 
detected in these places by the finger, passed carefully over the base 
of the tongue, and two fingers of the other hand resting in the fossa 
behind the angle of the jaw. This manoeuvre is especially adapted to 
detect fluctuation in cases of peritonsillitis. When suppuration occurs, 
which is the rule in interstitial and peritonsillitis, the height of the 
disease is reached in about seven days. Sometimes there is a sudden 
termination to days and nights of agony by the escape of a large quan- 
tity of pus, spontaneously or by incision. The opening may occur in 
sleep and the pus be swallowed, and the agreeable change in the condi- 
tion felt on awaking may not be explained. In some cases a number 
of days may be occupied in the escape of matter by several orifices, 
the improvement in the patient's state developing gradually. By slow 
progress in the formation of matter and by its gradual discharge, the 



16 



DISEASES OF THE DIGESTIVE SYSTEM. 



duration of the case may extend to two weeks. After the evacuation 
of pus, rapid improvement takes place. Food can now be swallowed 
and rest obtained ; the fever ceases, and the cavity of the abscess 
closes. Sometimes resolution takes place without proceeding to sup- 
puration ; then the progress of the case is slow, hyperplasia of the 
connective tissue occurs, and the organ remains permanently enlarged. 
Successive attacks of inflammation, of a rather subacute type, is the 
chief factor in the development of chronic hypertrophy. The termi- 
nation is rarely fatal. CEdema of the glottis has caused death. A 
large abscess developing in the course of an acute infectious disease 
may decide the case unfavorably. Death has been caused mechani- 
cally by the epiglottis being forced down by the swelling so as to 
close the entrance to the larynx, but this is an exceedingly rare event. 
The duration of follicular tonsillitis is about a week to ten days. The 
ulcers may be single or multiple, and a large excavation may be pro- 
duced by the coalescence of several small ones. When the slough is 
detached, the process of healing goes on rapidly, and the tonsil is more 
or less changed in form and structure by the new material and its sub- 
sequent contraction. Considerable loss of substance may be caused 
by the sloughing. 

Diagnosis. — As every step in the morbid process can be seen, there 
need be no difficulty in determining the character of the malady. It 
may not be easy to differentiate between peritonsillitis and interstitial 
tonsillitis, but, as suppuration is the objective point in both, it is of 
little consequence to be absolutely accurate. Ulcerative tonsillitis, 
with slough attached, may be confounded with diphtheria. The dis- 
tinction is made by observing that the apparent membrane is confined 
to the tonsil and to its follicles, and does not extend to the palate and 
other parts. 

Treatment. — A saline laxative should inaugurate the treatment 
unless the bowels are relaxed. Tincture of aconite-root (gtt i — iij) 
may be given every hour or two for the period preceding pus-forma- 
tion. Tincture of veratrum viride may be employed in the same way, 
and with the same limitation, but it is less efficient. Tartar emetic 
in small doses ( gr.) frequently, is also an efficient antipyretic, but, 
as it is apt to nauseate, the effects are unpleasant. Chlorate of potas- 
sa — a remedy now very popular, both with the laity and the profes- 
sion, because of its curative power in certain kinds of stomatitis, does 
not modify in any way the several varieties of tonsillitis. Besides its 
inefficacy in these affections, experience has shown that its frequent 
and persistent use may do serious mischief to the kidneys. In ulcera- 
tive tonsillitis, good results are obtained from the iodide of iron, of 
which a teaspoonful of the official sirup (properly diluted and taken 
through a glass tube) may be administered every four hours. In the 



GANGKEXE OF THE MOUTH. 



17 



other forms of tlie disease, the bromides of ammonium and potassium 
are highly beneficial, given with or without aconite, antimony, or vera- 
trum viride. When suppuration occurs, the best results are had from 
considerable doses of quinine, and a S}7iaU quantity of morphine, if the 
pain is very severe. 

The local treatment is rather more important than the systemic. 
If there be much tumefaction of the neck, great relief is afforded by a 
hot or cold wet pack. A gargle of hot milk and water, used every 
few minutes, is an efficient means of lessening the infl.ammation and 
swelling. Sometimes ice and cold water are more grateful, when they 
may be used instead. Bicarbonate of sodium, in powder, ^Dlaced on 
the base of the tongue, or a solution, in the form of a gargle, gives 
great relief, it is said, in cases of acute tonsillitis. When suppuration 
occurs, warm applications are to be preferred. If the tonsils come in 
contact in the median line and swallowing becomes impossible, great 
relief to the tension may be elfected by scarifications of the surface 
of the swollen bodies, and the bleeding encouraged by gargling with 
tepid water. When the formation of pus is rendered certain by the 
change in the color of the pointing part and by fluctuation, an incision 
should be made to evacuate the matter. 

Guaiacum has long been celebrated for its power to aiTest tonsillar 
inflammation. It should be given early, in scruple doses, for, if sup- 
puration have occurred, no remedy but to secure the discharge of mat- 
ter will be of any service. Another remedy supposed to have specific 
powers is ergot. The fluid extract may be given internally and ap- 
plied locally undiluted. Also a curative action, which has, apparently, 
an element of specificity, is had from mercury — calomel and hvdrar- 
gyrum cum creta — but this agent must be used w4th caution. 



GANGRENE OF THE MOUTH— NOMA. 

Causes. — Gangrene is a result in some cases of stomatitis ; but 
these are not, properly speaking, cases of noma, which is a special dis- 
ease, and occurs as an independent affection. It is a disease of early 
life — from three to five — and attacks the child of squalid poverty, or 
those living under the most unfavorable hygienic conditions. It is 
sometimes an accident of the incautious use of mercurials in unhealthy 
subjects. 

Morbid Anatomy and Symptoms.— The inner face of the cheeks, 
more usually of the left side, is the favorite site of the gangrenous 
process. At first a deep-violet or purple spot appears, surmounted by 
a vesicle full of bloody serum. Softening and destruction of the tis- 
sues take place, producing a quantity of sanies and detritus. Large 
4 



18 



DISEASES OF THE DIGESTIVE SYSTEM. 



excavations are thus formed, which widen as the destruction proceeds. 
A horrid stench is emitted from the decomposing mass. The jaws 
are eroded, the teeth loosened, and the lips invaded. Thromboses 
close the veins, but the arteries remain permeable ; the nerves are 
stained black, but are not otherwise altered in structure. If a cure is 
effected, very great deformities may result in the process of cicatriza- 
tion, and the functions of the parts be seriously impaired. 

Usually this disease begins silently and is painless, and hence 
escapes detection until the appearance of a grayish-black mass attracts 
attention to the mouth. When fairly inaugurated, the disease ex- 
tends so rapidly that distinctive symptoms are produced. A pro- 
nounced odor of animal decomposition is exhaled with the breath ; 
the lips and cheeks become swollen and oedematous ; the sublingual 
and submaxillary glands enlarge ; sanies and bloody saliva, mixed 
with the gangrenous and decomposing materials cast off from the 
sloughing ulcer within, are constantly flowing from the mouth. Mar- 
bling of the dirty, wax-colored skin with purplish, vein-like lines, and 
a central dark spot of commencing decomposition, indicate the out- 
ward extension of the gangrene to the cheek. 

As already indicated, during the first few days of the disease only 
local symptoms are present ; but then auto-infection ensues by reason 
of the absorption of the gangrenous materials, and an adynamic state 
is produced. Then the appetite is lost, nausea and vomiting occur, 
and a fetid diarrhoea supervenes. The strength fails rapidly, the pulse 
becomes small and weak, and low muttering or merely nocturnal de- 
lirium comes on. 

Course, Duration, and Termination.— The course and duration of 
the malady vary with the age, the vigor of constitution, and the hy- 
giene. The gangrenous eschar on the cheek usually forms within the 
first week, and death may occur by exhaustion at the end of the sec- 
ond week ; or the patient may be cut off by an intercurrent malady, 
notably pneumonia, at an earlier period. Pursuing its ordinary course, 
without complications, death may result from septicaemia in two weeks. 
When recovery takes place, the convalescence will be rapid or tedious, 
according to the amount of tissue to be repaired, and, even after the 
arrest of the gangrene, the powers of life may be exhausted by the 
extensive and protracted suppuration. The mortality is great, and 
ranges from sixty to seventy per cent. 

Diagnosis. — Noma is to be distinguished from malignant ulcer, 
and from ulcerous stomatitis. Malignant ulcer begins on the lip ; 
noma on the mucous membrane within. The former is an ulcer 
covered with an ash-gray slough ; the latter is a mass of blackish, 
gangrenous, decomposing tissues. The ulcero-membranous stomati- 
tis consists of a number of small, round ulcers, at various points, 



PHARYNGITIS. 



19 



that do not become gangrenous, and heal readily on appropriate 
treatment. 

Treatment. — Support to the powers of life is the main point, and 
this includes not only aliment but air-space. Alcoholic stimulants 
must be used early and freely. Quinine in full doses, and opium cau- 
tiously, should be given with the view to arrest the spread of the 
gangrene, and to prevent septicsemic infection. If administered at an 
early period, belladonna seems to possess the power to prevent the 
spread of the gangrene. It is very important to destroy the first 
sloughing tissue by active caustics, as Vienna paste, chromic acid, zinc 
chloride, muriatic acid, etc. The caustic must be so applied as to 
destroy a small extent of surrounding healthy tissue. Other efficient 
topical applications are resorcin, applied freely by insufflation after 
the separation of sloughs ; turpentine, conjoined with its internal ad- 
ministration, and compound solution of bromine (bromine, 3 i ; potas- 
sium bromide, 3 ij, and water, § j). 



CATARRHAL INFLAMMATION OF THE NASO-PHARYNGEAL 
MUCOUS MEMBRANE. 

Definition. — The upper pharynx, into which the posterior nares 
enter, is the seat of this inflammation. It may be acute or chronic. 

Causes. — Inflammation of the naso-pharyngeal space is usually a 
part of an inflammation involving the posterior nares and the lower 
pharynx. The most prolific cause is taking cold. Next to this is the 
use of cigarettes, especially if the smoke is inhaled and ejected by the 
nares ; and then comes alcoholic excess, but little less important. 
Diphtheria, the eruptive fevers, and inflammatory affections of the air- 
passages, are accompanied by this disease, and it may succeed them. 

Pathological Anatomy. — An intense hypersemia — a vivid redness- 
is the first change, but in chronic cases the color of the membrane is 
reddish-brown. As a result of the congestion, hsemorrhagic extrava- 
sations may occur. The mucous membrane is swollen, infiltrated, and 
projecting from the general surface are numerous enlarged follicles. 
Th§ increase in size of the follicles is due largely to the increase and 
accumulation of their cellular contents. The pharyngeal tonsils are 
enlarged from the swelling of the mucous membrane, and the orifices 
of the Eustachian tubes are changed in form by the same cause, or even 
obstructed. A quantity of glairy, tenacious mucus is poured out, and 
coats the surface of the membrane. In chronic cases, the mucous 
membrane is much altered by the enlarged and tortuous veins, by 
haemorrhagic extravasation, and by the hypertrophic enlargements 
of the follicles. In very old cases the mucous membrane undergoes 
atrophy. There is also increased secretion ; the mucus is mixed with 



20 



DISEASES OF THE DIGESTIVE SYSTEM. 



pus, and not unfrequently with blood, and a thick string of muco-pus 
can often be seen projecting down into the lower pharynx, behind the 
soft palate. Erosions of the epithelium also take place, and super- 
ficial ulcers form. 

Symptoms. — There is at first, in acute cases, an unpleasant, stuffy, 
and dry feeling in the naso-pharyngeal space, followed in a short time 
by increase of secretion falling into the pharynx or discharging by the 
anterior nares. There may be some headache and pains in the upper 
jaws. Breathing through the nose is difiicult. The voice is thick and 
nasal. The symptoms of an acute attack subside in a few days, the 
secretion changing to a yellow muco-pus from the transparent, glairy 
mucus which first appeared, breathing through the nose becoming 
natural, and the voice assuming its normal tone. 

In the chronic form, the symptoms succeed to the acute or develop 
slowly from the causes continuously acting. The posterior nares are 
more or less obstructed, constantly to a slight extent by the swelling 
of the mucous membrane, and occasionally very much by accumula- 
tion of mucus. Breathing through the nose may be sometimes pre- 
vented. The voice is more or less thick and nasal. Pain in the ear 
may be felt, and dullness of hearing is a common symptom from ob- 
struction of the Eustachian tube. The mucus, hanging down into the 
lower pharynx, excites frequent attempts to swallow, and causes a 
feeling of the presence of a foreign body. A disagreeable habit of 
hawking is induced in this way. In very chronic cases with atrophy 
of the mucous membrane, secretion ceases, and the membrane has a 
dry and glazed appearance. 

Course, Duration, and Termination.— The course of the acute form 
is short, and the termination is in health, or in the chronic form. The 
chronic form is very slow, and is usually regarded of importance only 
when a thick band of mucus hangs into the lower pharynx, and ex- 
cites efforts to clear the throat. As a not infrequent cause of deafness 
it comes under the observation of the aural surgeon. Although cu- 
rable under appropriate management, the treatment is very protracted. 
As success in the treatment requires abstention from the two preva- 
lent habits of smoking and drinking spirituous liquors, success will 
depend on the conduct of the patient very largely. Left to itself, the 
duration is indefinite. 

Treatment. — The first step in the treatment is to free the mucous 
membrane from the viscid discharge. This is best accomplished by 
washing out the cavity with the post-nasal syringe, employing a solu- 
tion of common salt or carbonate of sodium (3 j — 5 iv). The syringe 
is passed behind the vail of the palate, the fluid discharged, when, the 
patient leaning forward, it escapes into a vessel placed to receive it. 
So much damage to the ear has resulted from the incautious use of the 
nasal douche, that the author advises the curved post-nasal syringe for 



CATARRHAL INFLAMMATION OF THE LOWER PHARYNX. 21 



the purpose just indicated. Keeping the mucous membrane free from 
the unhealthy mucus is an important point. The agents used to bring 
about a cure of the chronic inflammation are very numerous. Strong 
applications are injurious. Those most frequently employed are the 
salts of zinc, copper, and silver. One grain of sulphate of zinc to four 
ounces of water is strong enough. The author finds that dry appli- 
cations — powders used by the method of insufflation — are greatly supe- 
rior in efficacy to all other modes of treatment. A mixture of tannin 
and iodoform is the best formula ( 3 j of tannin — gr. x of iodoform). 
A minute quantity of this is put into the chamber of the insufflator 
and blown into the naso-pharyngeal space. This instrument must 
have a long tube, and be suitably curved, so that it can be passed be- 
hind the palate. The salts of zinc, copper, and silver, iodoform, calo- 
mel, bismuth, may be used in the same way. Next to tannin and 
iodoform, insufflations of bismuth are most useful. When the former 
produce much irritation, the author uses bismuth in the interim of the 
applications. 

CATARRHAL INFLAMMATION OF THE LOWER PHARYNX. 

Pathogeny and Symptoms. — This may be acute or chronic. Both 
forms arise under precisely the same conditions as the corresponding 
maladies of the naso-pharyngeal space. The changes in the acute form 
consist of redness, swelling of the mucous membrane, enlargement of 
the follicles from accumulation of their contents, and increased secre- 
tion, coming on after a very brief dry stage. These anatomical condi- 
tions are not limited to the pharynx. In the chronic form, the changes 
are more decided. The mucous membrane is of a deep reddish-brown, 
or, in very old cases, grayish. The vessels of the mucous membrane 
are enlarged and tortuous. The follicles are enlarged and prominent, 
and have a grayish or reddish-gray color ; there may be considerable 
development in places of the squamous epithelium, and ulcers, rather 
shallow than deep, form in various situations. The symptoms are by 
no means pronounced. Dryness, a sense of heat and irritation, a feel- 
ing as if something were adherent to the mucous membrane, much 
hawking and clearing the throat, are the chief sensations. On inspec- 
tion of the fauces the mucous membrane is seen to be of a deep, red- 
dish-brown color, thick, coated with a tenacious mucus, and roughened 
by enlarged follicles. In very old cases the posterior wall of the phar- 
ynx is smooth, thin, and glazed, in consequence of atrophic changes 
succeeding to the inflammatory, and has adherent to it dry masses of 
mucus, colored by dust. 

Treatment. — The principles and the methods of practice advised 
for the naso-pharyngeal space are equally applicable here. 



22 



DISEASES OF THE DIGESTIVE SYSTEM. 



RETRO-PHARYNGEAL ABSCESS. 

Definition. — By this term is meant an accumulation of pus in the 
submucous connective tissue, posterior to the pharyngeal wall. An 
abscess may form in the mucous membrane itself — this is entitled 
pharyngeal abscess. 

Causes. — Diseases of the cervical vertebra, of the atlas and axis, 
as caries, are the principal causes. Large collections are formed in 
the same situation, from suppuration in the bronchial glands, and in 
the deep cervical lymphatics — the pus dissecting up under the mucous 
membrane, and pointing in the pharynx. Again, an abscess may be 
the result of an inflammation of the loose connective tissue, under the 
pharyngeal mucous membrane, a disease not infrequent in children 
before the tenth year. 

Symptoms. — The abscess produced by an acute inflammation of the 
connective tissue is very acute in its course. It begins with chill, high 
fever, sleeplessness, intense restlessness, and in very young children 
there may be convulsions. When the abscess results from caries of 
the vertebrae, its march is slower, and the symptoms of pharyngeal 
obstruction are the first to call attention to this part. Pain in moving 
the head is felt, and hence it assumes a fixed position, the cervical 
muscles being rigid. Then difliculty of swallowing and dyspnoea come 
on. If digital exploration is then made by passing the index-finger 
gently over the base of the tongue, a hard, brawny, possibly fluctuating 
swelling may be detected in the pharynx. The neck will also be much 
swollen externally, and fluctuation may ultimately be felt under the 
angle of the jaw. Suppuration is often announced by the occurrence 
of a chill, and the fever will then assume an intermittent or remittent 
type, and profuse sweats will occur. The abscess, if not interfered with 
by art, will discharge spontaneously into the lower pharynx, or exter- 
nally, or form fistulous communication with the cavity. The author has 
seen one case in an adult, which extended from the basilar process to 
the root of the lungs. When spontaneous opening of the abscess takes 
place, suffocation may be caused by escape of the matter into the 
larynx. Death may also be caused by the size of the collection, the 
larynx being occluded, or by secondary disease of the air-passages, or 
by thrombosis of the transverse sinus, or jugular vein, or even of the 
carotid artery. 

Course, Duration, and Termination.— There are great differences, ac- 
cording to the origin of the abscess, in the course pursued. Those due 
to caries of the vertebra are slow in development, but fatal in result. 
The phlegmonous abscess is acute, pursues its course in from five to 
twenty days or longer, and the danger is determined by the size of the 
collection, and the direction taken by the pus if not spontaneously 
evacuated. If not large, the abscess will discharge and heal without 



OESOPHAGITIS. 



23 



danger to life. The large submucous abscess will almost always 
prove fatal by exhaustion. 

Treatment. — Pus should be evacuated at the earliest moment. 
The powers of life must be sustained by proper aliment and the free 
use of stimulants. The formation and spread of pus must be limited 
by the administration of quinine, as far as such a result is possible, and 
by calcium sulphide, malt extract, the hypophosphites, phosphates, etc. 



DISEASES OE THE (ESOPHAaUS. 



CATARRH OF THE CE SOPH AGUS.—CE SOPH AGITIS. 

Causes. — Acute oesophagitis exists only as a part of a morbid pro- 
cess involving the mouth, fauces, and stomach. Typical examples are 
afforded by the action of irritant poisons and corrosive substances. 
The chronic variety is produced by the causes which give rise to the 
chronic stomatitis. The acute and chronic forms differ so little that 
they may be considered together. The change in the mucous mem- 
brane consists in more or less hyperaemia, especially about the follicles ; 
at first an arrest of secretion, followed by an abundant pouring out 
of mucus, which in the chronic form is always in excess. Consider- 
able hypertrophic thickening of the mucous membrane occurs in the 
chronic malady, and in some situations takes on the form of papillary 
or polypoid-like outgrowths. Coincident thickening of the muscular 
layer also occurs. Erosions of the mucous membrane, at first super- 
ficial, are produced by disintegration and separation of the epithelium, 
and ulcers are then formed, which may extend to the deeper layers. 
The greatest diameter of these ulcers is parallel to the long axis of 
the tube. Ulcers also result from the impaction of foreign bodies ; 
from corrosive liquids ; from tubercular deposition, etc. The catarrhal 
form may be confined to the follicles, when it is called follicular 
oesophagitis. The follicles are swollen and prominent, partly in con- 
sequence of an abnormal accumulation of their contents, and partly in 
consequence of an hypertrophy and contraction of the adjacent con- 
nective tissue. The diseased follicles appear as firm nodules, some- 
what conical in shape, projecting above the general surface, and irreg- 
ularly distributed along the tube. A fibrous or croupous oesophagitis 
also exists, not as an independent affection, but consisting of an exten- 
sion downward of an exudation, croupous or diphtheritic, or occurs as 
a complication in typhus, scarlet fever, small-pox, etc. There is, also, 



24 



DISEASES OF THE DIGESTIVE SYSTEM. 



a phlegmonous or purulent inflammation of the oesophagus, which 
comes on by extension of purulent infiltration of neighboring parts, as 
in perichondritis of the larynx, by the action of corrosive substances, 
by lodgment of foreign bodies, etc. 

Symptoms. — In either acute or chronic form, oesophagitis produces 
but few symptoms. Pain in swallowing is usually present in the acute 
form, and may be developed in the chronic cases by the ingestion of 
hot or rough foods. Pain may be caused by pressure on the tube from 
without, and by the passage of an oesophageal bougie — a procedure by 
which we may designate the seat of ulceration, or lesser kinds of irri- 
tation, even. When there is severe local disease at any point, as an 
ulcer, for example, food swallowed descends to that point, excites a 
sensation of heat and pain, and is then regurgitated by a sudden reflex 
spasm of the tube. Sometimes mucus or muco-purulent matter will 
be found adherent to the particles of food. Chronic catarrh is espe- 
cially characterized by the production of much glairy and tenacious 
mucus, which rises into the pharynx, causing the sensation of the 
presence of a foreign body. The attempt to clear the throat of this 
often excites gagging. These symptoms are, not unfrequently, con- 
founded with those due to corresponding diseases of the throat, espe- 
cially chronic and follicular catarrh. 

Course and Duration. — Simple acute catarrh terminates in a few 
days. When produced by corrosive liquids, the process of cicatriza- 
tion will occupy several weeks, and subsequent contractions and stric- 
tures may so interfere with nutrition as to cause death by marasmus 
after many months. The chronic, and especially the follicular, variety 
may continue unchanged for years. 

Treatment. — The management of the various forms of oesophagitis 
is the same as the corresponding affections of the mucous membrane of 
the mouth. The topical applications must necessarily be restricted to 
the agent swallowed. 

DYSPHAGIA. 

Dysphagia, or difliculty of swallowing, is a symptom of disease, 
but not a disease itself. It is frequently hysterical, when it is accom- 
panied by other hysterical manifestations, as the globus hystericus, 
laughing and crying, etc. It may be hypochondriacal, when the pa- 
tients present the deep dejection, the indifference, and other symptoms 
of that state. It may be due to stricture, succeeding to injury by 
steam, corrosive liquids, injuries of various kinds, cicatricial tissue, 
malignant disease, etc. It may also be due to paralysis of the palate, 
a sequel of diphtheria. It will be more appropriately considered when 
these topics are discussed. 



STENOSIS OF THE (ESOPHAGUS. 



25 



STENOSIS OF THE CESOPHAGUS. 

Causes. — The term stenosis signifies narrowing of the oesophagus, 
produced in various ways. It may be congenital or acquired : the lat- 
ter only will be considered here. As regards acquired stenoses, they 
may be produced by causes acting from without, by compression ; 
within, by obstruction. As respects those acting from without, we 
find the lumen of the oesophagus narrowed by tumors, the enlarged 
thyroid, aneurisms, caseous lymphatics, etc. Obstructions from the in- 
terior are caused by foreign bodies lodged, which usually produce acute 
symptoms, but sometimes remain, lodged in pockets or diverticula, 
for months or years. Parasitic growths gradually developing may 
cause stenosis. Fibroid polypi, club-shaped or lobulated, slowly ob- 
struct the canal, and hence cause the symptoms of obstruction very 
slowly. Strictures are formed by the contraction of cicatrices, or by 
carcinoma. Cancerous stenoses are more frequent than all the others 
combined. Their usual seat is the lower third of the canal, and they 
may involve the whole periphery and a considerable part longitudi- 
nally. 

Symptoms. — Increasing difficulty in the passage of food, which the 
patient recognizes at a certain point, is usually the first symptom ex- 
perienced. Swallowing is successful, but the patient feels a sense of 
obstruction below, requiring at first repeated attempts at swallowing 
to overcome ; then repeated sips of water, with more swallowing to 
dislodge the bolus ; and, when the obstruction reaches a certain point, 
regurgitation occurs, not in consequence of an inverted peristalsis, but 
the mechanical effect of partial compression of a tube containing liquid 
contents. The position of the obstruction is pretty accurately indi- 
cated by the sensations of the patient and by the time when regurgi- 
tation takes place. In acute stenosis — from burns, scalds, and corro- 
sives — and in chronic carcinoma, when complete obstruction occurs, 
food is regurgitated as soon as swallowed. The physical signs of 
stenosis are important. On inspection in thin persons, the movement 
of the bolus may be seen descending to the point of stoppage if high 
enough up, or the return movement may be discerned. Enlarged lym- 
phatics may be visible at the root of the neck, and the abdomen, 
especially the hypochondria, may be flattened and retracted, indicat- 
ing starvation. On auscultation the normal oesophageal sound pro- 
duced by the passage of foods may be heard suddenly arrested at the 
point of obstruction and passing upward on regurgitation, or various 
adventitious sounds may be audible, as gurgling, sucking, spluttering, 
etc., at the point of narrowing. An important symptom is spasin of 
the glottis, produced by pressure of a growth, especially cancerous, on 
the recurrent laryngeal nerve. A peculiar cough, sudden paroxysms 
of difficult breathing, and a toneless voice, are thus caused. Difficulty 



26 



DISEASES OF THE DIGESTIVE SYSTEM. 



of breathing may also be due to pressure on the trachea simultaneously 
with the oesophageal pressure. The most tormenting hunger and thirst 
arise in the progress of the case, and increase with the increasing dif- 
ficulty of getting aliment in the stomach ; the body emaciates to an 
extraordinary extent ; the mind is incessantly occupied with thoughts 
of savory viands, and, in the delirium with which the scene closes, the 
hapless patient is engaged with the most sumptuous repasts. 

Diagnosis. — The spasmodic stenosis of the hysterical and hypochon- 
driacal is accompanied by the usual symptoms of these states, and the 
condition of the patient as to nutrition is not in harmony with the 
gravity of the local phenomena. Acute stenosis is preceded by the 
history of injury by scalding or burning, or by the ingestion of corro' 
sive liquids. The question of cancer is to be considered with refer- 
ence to the age, which is, almost always after forty-five, and the de- 
velopment of the disease is marked by a gradually increasing difficulty 
of swallowing, by marasmus, and the cancerous cachexia. External 
compression may be produced by enlarged lymphatics, by an hypertro- 
phied thyroid, by mediastinal and cervical tumors; but these can easily 
be differentiated from all kinds of internal obstruction. An aneurism 
of the arch of the aorta, by compression of the oesophagus and of the 
recurrent laryngeal nerve, will cause symptoms not unlike those due 
to cancer of this tube ; but there will be present the signs of aneurism. 
Diagnosis will in all cases be greatly facilitated by the oesophageal 
bougie ; but this instrument must be used with caution when the canal 
is much injured, lest perforation be produced by its passage. 

Prognosis. — The termination is fatal in a large proportion of cases 
of stenosis ; but excellent results may, sometimes, be obtained by the 
patient and persistent use of the means of dilatation in cases of steno- 
sis by cicatrices. 

Treatment. — So far as medical management is concerned, it is de- 
termined by the causes of the obstruction, and it is not our province to 
discuss surgical expedients. 

DILATATIONS OF THE CESOPHAGUS. 

Causes and Symptoms. — Dilatation is a uniform enlargement of the 
oesophagus, the whole cylinder usually being involved. A diverticu- 
lum is a protrusion from the walls laterally, forming a sac of greater 
or less extent. Ektasia may be caused by fatty degeneration of the 
muscular layer, which yields in the act of contracting on the bolus as 
it descends to the stomach. With increasing dilatation, there is in- 
creasing weakness of the muscular layer and consequent dysphagia. 
Vomiting and regurgitation presently occur ; after a while the nutri- 
tion fails, and the objective symptoms are similar to those of stenosis, 
the ultimate result being equally unfortunate. Diverticula may be 



DILATATIONS OF THE (ESOPHAGUS. 



27 



caused by the lodgment of foreign bodies leading to the formation of 
pouch-like protrusions. Pressure diverticula are usually situated at or 
about the junction of the pharynx with the oesophagus, and in the 
median line, posteriorly, for here the longitudinal muscular fibers are 
wanting and the pressure is greatest. When fully formed, they are 
deep pockets, or sacs, of varying length, and may be several inches 
deep. The first step in their formation is the lodgment of a foreign 
body ; then yielding of the muscular layer of the tube, due to fatty 
degeneration of the muscular elements ; increasing pressure from de- 
posits of food and drink ; the final result being a sac extending down- 
ward and behind the oesophagus. The mechanical effect of a sac in 
this situation is to push the tube before it and compress it, so that ulti- 
mately the food and drink drop into the sac instead of passing into 
the stomach, thus causing the symptoms of stenosis. The symptoms, 
however, develop more slowly than in even the most chronic cases of 
stenosis. Diverticula occur in the great majority of instances after 
forty, whence it happens that they are often confounded with cancer ; 
there is no cachexia, and the symptoms continue for years. A bulg- 
ing, variable in size, may often be observed above the level of the cri- 
coid cartilage ; this marks the position of the diverticulum within. 
The food accumulating here may, by the contraction of the cervical 
muscles or by the fingers of the patient, be dislodged and is then 
regurgitated. The sound enters the sac, but is not tightly embraced 
by it, as is a stricture, and moves about freely in the cavity. Traction 
diverticula are found low down, opposite the bifurcation of the trachea, 
and are caused by various inflammatory conditions leading to adhesion 
with the oesophagus. The traction thus caused induces the formation 
of diverticula. 



DISEASES OF THE STOMACH. 



FORMS AND VARIETIES. 

The diseases of the stomach are named according to their charac- 
ter and anatomical seat. Inflammation of the stomach is called gas- 
tritis, and may occur in the mucous membrane, or in the submucous 
connective tissue. The mucous variety is known as gastric catarrh, 
and then consists of two forms — acute and chronic ; the submucous 
variety is designated phlegmonous or interstitial gastritis, and may 
also occur in two forms — acute and chronic ; the latter is sometimes 



28 



DISEASES OF THE DIGESTIVE SYSTEM. 



called cirrhosis of the stomach. There is also a form of gastritis 
caused by the ingestion of corrosive and irritant poisons — toxic gastri- 
tis. Under the term emharras gastrique the French authors describe 
a light form of gastric catarrh, due to the use of various kinds of indi- 
gestible aliment. Severe cases of gastric catarrh, in which, in addition 
to the ordinary symptoms of indigestion, there is present fever, lasting 
about a week, have been called gastric fever. Chronic gastric catarrh 
is only another name for dyspepsia. 

ACUTE GASTRITIS. 

Causes. — The stomach is much affected by atmospherical changes. 
An illustration of this is afforded in the summer and autumnal attacks 
of bilious and gastric fevers, so called, induced as they are by the very 
considerable vicissitudes of temperature, the hot days and cool nights 
of the autumn. Gastric catarrh occurs at all ages after infancy, and 
is more frequent in men than in women. The most common causes 
are errors of diet, insufficient mastication of food, swallowing too hot 
or too cold liquids, excessive eating, abuse of ices, condiments, and 
sauces, etc. ; and especially of alcoholic drinks. Various external influ- 
ences and moral causes affect the digestive functions, as occupation^ 
exercise, sedentary habits, grief, etc. 

Pathological Anatomy. — In the simplest cases, the lesions may be 
so slight as to escape detection ; in mild but fully developed cases the 
changes are about as follows : The mucosa is the seat of a delicate in- 
jection occurring in isolated spots, arborescent or generalized to the 
whole membrane. Usually at or near the cardiac orifice, the injection 
or hyperaemia is most pronounced. The mucous membrane may be 
intensely engorged, and covered with a grayish, semi-transparent, and 
tenacious mucus (Orth). It should not be forgotten that enormous 
congestion of the stomach may exist in cases of mitral obstruction 
and regurgitation. The similarity of this to true catarrhal states is 
rendered the more confusing, because of the quantity of glairy and 
tenacious mucus found attached to the mucous membrane so firmly as 
to be washed off with difficulty (Wilks and Moxon). The mucous 
glands are prominent, and are increased in size above the normal, in 
consequence of the overgrowth of their contained cells and the hyper- 
trophy of the adjacent connective tissue. In chronic cases, the glands 
have shrunk (atrophy), or have become cystic, in some situations, 
because of the pressure produced by the contracting connective tissue. 
Sometimes the mucous membrane is softened and easily stripped 
off ; then again, it is indurated and much thickened, in consequence 
of interstitial inflammation. Much confusion has arisen in regard 
to the term " mammillated," which consists in the formation of 
numerous small, conical eminences, by the contraction of the sub- 



ACUTE GASTRITIS. 



29 



mucous connective tissue, or of the muscular layer, similar to cutis an- 
serina. This appearance can not be regarded as morbid, unless asso- 
ciated with other anatomical changes, Ecchymoses are found, and also 
dark, brownish patches, the result of subsequent changes in the effused 
blood. Erosions also occur here and there of various sizes, but not 
often of considerable size, and just about them the mucous membrane 
is softened. An oedematous appearance of the mucous membrane is 
caused by an infiltration by serum and sero-albumen of the submucous 
connective tissue. The proper secretion of the gastric glands is much 
affected by these anatomical alterations. The true gastric juice is no 
longer secreted, or its production is much lessened, and it is replaced 
by an alkaline fluid having no power of digestion. 

Symptoms. — The initial morbid changes, doubtless, precede the oc- 
currence of objective symptoms. At first, diminution of appetite, 
labored digestion, nocturnal restlessness, inability to undergo fatigue, 
supra-orbital headache increased by light, by noises, and by move- 
ments of the head, and sometimes accompanied by vertigo, are the 
symptoms experienced. In some instances, the vertigo is extreme ; 
the patient may fall unconscious for a few seconds, and the vertigi- 
nous attacks may be confounded with symptoms of the same kind due 
to cerebral lesions. Pain is felt at the epigastrium, spontaneous or 
developed by pressure. The epigastric pain may have a boring char- 
acter, as if passing through the body straight to the spinal column, or 
under the angle of the scapulaB. Pain is frequently felt in the left 
hypochondrium, two inches under the left nipple, or in the immediate 
vicinage of the apex-beat. The tongue is enlarged, marked laterally 
by the indentations of the teeth, and is covered over its whole extent 
with a whitish or a yellowish-white coating. The taste is perverted, 
indifferent, bitter, or putrid. Especially on rising in the morning is 
the mouth pasty, sticky, and filled with a bitter-tasting mucus. The 
appetite is totally lost (anorexia), and the thought of food-taking, 
especially the appearance of food, excites a sensation of disgust ; but 
considerable thirst is experienced, and drinks, particularly those of an 
acid character, are eagerly sought after. Nausea is present in varying 
intensity, and there is usually vomiting, at first consisting of the ali- 
mentary substances, then viscid mucus acid and bitter, and finally 
bilious matters. Bilious vomiting is commonly supposed to indicate 
special disturbance in the hepatic function, but it really means that 
by the act of vomiting the gall-bladder is mechanically compressed, 
and its contents forced through the duodenum into the stomach. The 
amount of vomiting is usually determined by the amount of food pre- 
viously taken. If the result of an indigestion, the vomiting is copi- 
ous ; but, under other circumstances, it may occur only occasionally, 
aud then be slight. The sufferings of the patient are always aggra- 
vated by errors of diet, and vomiting is certainly provoked by eating 



30 



DISEASES OF THE DIGESTIVE SYSTEM. 



indigestible food. A foul odor of the breath, eructations of fetid gas, 
are due to a failure of digestion, and the occurrence of decompositions, 
the character of which, and the resulting products, being due to the 
kind of food undergoing this process. Saccharine and starchy foods 
become converted into carbonic and acetic acids ; the fatty result in 
setting free irritating fat acids, and the substances containing sul- 
phur and phosphorus give forth the highly fetid compounds of hydro- 
gen — sulphuretted and phosphuretted hydrogen gases. Acidity and 
heartburn (pyrosis) are thus caused, and tympanitic distention of the 
stomach results from the setting free of a great quantity of carbonic- 
acid gas. The intestinal functions may or may not be disturbed. Usu- 
ally there is present slight constipation ; yet, if the attack is brought 
on by the use of indigestible aliment, more or less diarrhoea may occur, 
and it may be conservative. Mild cases of acute gastric catarrh may 
not excite the least disturbance in the heat-function, but in young and 
susceptible subjects there may be some feverishness, the movement 
being of a remittent type, the maximum temperature rarely exceeding 
103° Fahr. When the stomach disturbance is extreme, and the fever 
persists for several days, the cases are sometimes entitled gastric fever, 
or they are confounded with remittent fever, especially in malarious 
regions. 

Course and Duration. — The duration of acute catarrh of the stom- 
ach is four days to a week. A sudden and rapid cure is sometimes 
effected by a spontaneous or a forced evacuation, by vomiting, by 
purging, or by a urinary discharge. The beginning of convalescence 
is sometimes announced by an eruption of herpes, or by a profuse 
sweat. 

Diagnosis. — Acute gastric catarrh with fever may be confounded 
with remittent and typhoid fever of the first week, but all doubts will 
disappear as these maladies develop. Vertigo a stomacho laeso (Trous- 
seau) is to be distinguished from similar symptoms due to cerebral 
hypersemia. The distinction rests on the age of the subject, the pres- 
ence or absence of degenerative changes in the vessels, and of the 
arcus senilis, the history of stomachal troubles, the fugitive character 
of the symptoms, and the prompt disappearance of the stomach-disease 
when efficient treatment is instituted. 

Treatment. — Simple cases of acute catarrh of the stomach need only 
abstinence and quiet. If the stomach is much embarrassed, and excesses 
of the table have been recently committed, or some specially irritating 
articles of diet have been consumed, free emesis is the most effective 
treatment. The salts of the metals belonging to the class of emetics 
,are too irritating for this purpose. If vomiting have occurred, it may 
be encouraged by swallowing large draughts of warm water, which 
will act as a sedative if the stomach is empty. Weak alkaline mineral 
waters — as Congress, Hathorn, and Yichy of the Saratoga Springs, 



TOXIC GASTRITIS. 



31 



and the French Yichy — should be drunk freely. Unhealthy and undi- 
gested aliment, which has reached the intestines, should be dislodged 
by saline laxatives. When there is much biliousness — so called — 
manifested by a heavily-coated tongue, vertigo, headache frontal and 
temporal, yellow skin, more or less constipation, urine high-colored, 
acid, scanty, etc., the mercurial purgatives are held to possess some 
special curative powers. This is probably true to a limited extent, 
not because of any action on the liver, but because they increase elimi- 
nation from the excretory glands of the lower ilium. Podophyllin, 
iridin, euonymia, and ipecac, are nearly equally effective, but calomel 
in small doses (one twelfth of a grain) has remarkable sedative effects 
on an irritable stomach. The officinal effervescing powders, carbonic- 
acid water, milk, and lime-water, are excellent remedies to check vom- 
iting. A mixture in equal parts of carbolic acid and iodine tincture, 
of which a drop may be taken, well diluted with water, every few 
hours, is a most valuable remedy to arrest abnormal fermentations and 
to check vomiting. A mixture of bismuth and carbolic acid with mu- 
cilage, in mint-water, is hardly less efficient. After the more acute 
symptoms have subsided, the tincture of nux-vomica and the diluted 
muriatic acid are suitable remedies to improve the tone of the stomach 
and to restore the appetite. 



TOXIC GASTRITIS. 

Causes. — As already defined, toxic gastritis is an acute inflamma- 
tion of the stomach, caused by the ingestion of irritant and corrosive 
poisons. 

Symptoms. — So far as the symptoms are concerned, there is no 
essential difference in the effects produced by the different irritant and 
corrosive poisons. Immediately on swallowing, there ensues a deadly 
nausea, rapid and uncontrollable vomiting, the matters rejected con- 
sisting of the contents of the stomach acted on by the poison, shreds 
of mucous membrane, altered blood-clots, etc. A diagnosis of the 
form and chemical characteristics of the poison may sometimes be 
made by observing the character of the stain of the face, lips, and 
mucous membrane— sulphuric acid causing a friable, blackish eschar ; 
nitric acid a yellowish, leathery eschar ; caustic potash spreading 
widely, softening, and liquefying the tissues. In the stomach, dark- 
brown, greenish, or black discoloration s, with masses of sloughing 
mucous membrane, are observed. It is rare that the whole mucous 
membrane of the stomach is uniformly attacked. Usually there is 
considerable discoloration — uniform, indeed, about the cardia, at the 
greater curvature, and at the pylorus, leaving large portions un- 
touched. Sometimes only the mucous membrane about the cardia 
and at the pylorus is attacked (Wilks and Moxon) ; the extent of the 



32 



DISEASES OF THE DIGESTIVE SYSTEM. 



action and tbe resulting appearances depend on the degree of con- 
centration of the corrosive material. Sometimes the walls of the 
stomach are perforated, a result more frequently due to the action of 
alkalies than acids. The mineral poisons — arsenic, the salts of mer- 
cury, copper, zinc, nitrate of potash, etc. — produce an intense inflam- 
mation with vivid redness and injection. Carbolic acid acts super- 
ficially, and hardens and tans the mucous membrane. 

Similar results follow the ingestion of certain kinds of food cooked 
in copper vessels and containing the acetate and other salts of copper, 
or articles of food that have undergone decomposition, such as sau- 
sages, hams, cheese, fish, etc. A violent gastro-enteritis is produced in 
a few minutes or hours after the swallowing of such aliments. Besides 
the local there are various systemic symptoms, produced by irritant 
poisons, either due to the diffusion of the poison or to the reflex dis- 
turbance resulting from violent local irritation. Besides the vomiting 
mentioned above as occurring immediately or very soon after swal- 
lowing the irritant, corrosive, or toxic substance, purging sets in, and 
the same sanies, detritus, and sloughs of the tissues discharged by 
vomiting pass also by stool. In the case of corrosive sublimate and 
the metallic salts generally there occur intense colic and tenesmus, and 
the discharges consist of mucus and blood, and strongly simulate 
dysentery. Whether or not diffusion of the poison or irritant takes 
place, there occur great anxiety and depression, a weak, rapid pulse, 
slow and shallow respiration, cold skin, covered with a cold sweat, 
retracted features, intense internal heat and thirst, burning in the 
gullet and fauces — the lips, tongue, cheeks, and fauces, charred, cor- 
roded, or softened by the contact of the poison. 

Course^ Duration, and Termination. — The characteristic feature of 
toxic gastritis is the suddenness with which symptoms arise, after 
swallowing some solution or eating certain articles of diet. Soon 
severe pains in the stomach, violent vomiting, and other symptoms 
occur, the patient having previously been in good health, it may be. 
Death may occur from the immediate effects of the poison, from the 
shock of the injury done to the organs, from the shock and subsequent 
perforation of the stomach, and peritonitis, combined. Recovery may 
ensue if the injury done is not too great for repair, the patient passing 
safely through the period of shock and collapse. The evidences of 
improvement consist in subsidence of the pain and vomiting, in re- 
turning tolerance to food which is bland and unirritating, in the dis- 
appearance of all the symptoms of collapse. Surviving the first injury, 
a fatal result may be subsequently due to the inflammation which fol- 
lows. The convalescence is necessarily tedious, owing to the' very 
limited surface capable of carrying on the function of digestion. 
Recovery is apt to be partial, and the nutrition ever after is 
feeble, owing to the extent of injury — the cicatrices and contraction 



CHRONIC GASTRIC CATARRH. 



33 



of tlie stomach, the stenoses of the orifices of this organ, and of the 
oesophagus. 

Treatment. — Vomiting is to be encouraged by the free use of de- 
mulcent drinks. If the toxic agent consists of an acid, as speedily as 
possible weak alkalies, lime-water, soda, common soap, etc., should be 
administered. If the offending substance is a caustic alkali, weak 
acids, common vinegar, diluted acetic acid, etc., should be given. The 
various mineral salts require their appropriate antidotes : arsenic, 
dialyzed iron, or hydrated sesquioxide of iron ; antimony, vegetable 
astringents, as green tea, galls, and oak-bark infusion ; mercury and 
copper, albumen and mucilaginous substances ; phosphorus, turpen- 
tine, magnesia, etc. ; carbolic acid, saccharated lime. The stomach- 
pump should be used not only to remove the poison remaining, but to 
thoroughly wash out the stomach. To allay pain, and counteract the 
depression of the powers of life, no agent is comparable to the hypo- 
dermatic injection of morphia. Ice should be given freely, and an ice- 
bag applied to the epigastrium. The morphia must be repeated at 
regular intervals. No food should be given but a little cold milk at 
short intervals. Injections of defibrinated blood may be practiced 
with great advantage as a means of support. The subsequent man- 
agement depends on the character of the poison, and the nature and 
extent of the injuries. 

PHLEGMONOUS OR INTERSTITIAL GASTRITIS. 

Definition. — By this term is meant an inflammation of the walls of 
the stomach, usually of the submucous layer, and resulting in the forma- 
tion of an abscess, or in purulent infiltration of the parietes. These 
abscesses may be single or multiple. 

Causes. — Phlegmonous gastritis may occur during the course of 
pyaemia, or be due to hsemorrhagic infarction or to hepatic obstruc- 
tion. These abscesses may be acute or chronic. 

Symptoms. — The symptomatology of phlegmonous gastritis is ex- 
ceedingly obscure. The ordinary course is as follows : Usually sud- 
denly, or after an irregular prodromal stage, the patient is seized with 
epigastric pain, followed by nausea and vomiting, thirst, a weak and 
irregular pulse, great distention of the abdomen, and diarrhoea. Pro- 
found prostration comes on, and finally a low delirium and death. 
These symptoms do not indicate the nature of the malady. 

As it is doubtful whether such cases are ever recognized, the treat- 
ment must be conducted on general principles. 

CHRONIC GASTRIC CATARRH. 

Causes. — The chronic form may succeed to the acute. Heredity 
exercises an influence in its causation ; not in the sense that the dis- 
5 



34 



DISEASES OF THE DIGESTIVE SYSTEM. 



ease is directly transmitted, but the type of mucous membrane. Bad 
hygienic influences of every kind, especially miasmatic influences, and 
all manner of irregularities of life, are causative. The abuse of spir- 
its, and the habitual consumption of highly-seasoned foods and of con- 
diments and sauces, hasty and insufficient mastication, the frequent use 
of ices, and overfeeding, are the principal causes of chronic gastric 
catarrh. 

Pathological Anatomy. — The most important changes occur about 
the pylorus. The evidences of previous hypersemia exist in a brown- 
ish discoloration due to hgemorrhagic extravasation and subsequent 
changes in the htematin, and in more or less varicosity of the vessels. 
There is constantly present more or less hyperaemia, but not the intense 
and vivid injection seen in acute catarrh. The abnormal supply of 
blood to the submucous connective tissue leads to overgrowth (hyper- 
plasia, hypertrophy), and this new material contracting, forces the 
glands into abnormal prominence, causing that appearance known as 
mammelonated ; but it should not be forgotten that this appearance 
may be due to a contraction of the organic muscular fiber without the 
existence of any disease whatever. The gland-tubules also increase in 
size in consequence of overgrowth of their contents, and they produce 
a quantity of grayish or yellowish, thick, tenacious mucus, which cov- 
ers closely and adheres to the surface of the mucous membrane. The 
overgrowth of connective tissue increases the thickness of the mucous 
membrane and its resistance to section. Compression of the tubules 
(glands), by the contracting connective tissue, induces atrophy of their 
cells. Here and there a gland is obstructed ; its secretion having no 
outlet, accumulates, and a cyst is the ultimate result. 

Symptoms. — When a chronic succeeds to an acute catarrh of the 
stomach, the attacks of the latter become increasingly frequent, and 
presently it is found that the patient is never free from uneasiness and 
other painful sensations referable to the stomach. This painful and 
otherwise disordered digestion is commonly known as dyspepsia. 

When chronic catarrh exists the. patient is rarely free from some 
disagreeable sensations, but it is after taking food, chiefly, that he 
experiences a feeling of weight or fullness, sometimes of pain ; but 
acute pain of a lancinating character, especially when it seems to pass 
directly through to the back, is more frequently due to neuralgia — 
gastralgia — or is a symptom of ulcer or of cancer. On the other hand, 
attacks of neuralgia do sometimes occur in the course of chronic gas- 
tric catarrh ; but the pain of the latter is more often a sense of sore- 
ness diffused over the epigastrium, the greater curvature, and is some- 
times felt only in the left hypochondrium. Sometimes this pain may 
be relieved by pressure ; but more usually pressure over the stomach, 
at any point, develops uneasiness, soreness, or pain. As the pit of the 



CHRONIC GASTRIC CATARRH. 



35 



stomach, so called (the triangular space under the xiphoid appendix), is 
occupied by the left lobe of the liver, and as the stomach lies well up 
in the left hypochondrium, these facts must be taken into considera- 
tion in coming to a conclusion in regard to the seat of pain. Some- 
times when the stomach is empty, sometimes when it is full, the pain 
is greater ; sometimes the pain is relieved by taking food, sometimes 
it is increased thereby. These idiosyncrasies give to each case a pe- 
culiar physiognomy. The subjective sense of fullness is confirmed by 
the objective swelling of the stomachal region. After meals, the dis- 
comfort caused by the distention is such that the mere pressure of the 
clothing gives rise to pain. This feeling of distention is due in part 
to an irritable state of the mucous membrane, but more especially to 
the formation of the gases of decomposition. In the normal state, the 
gastric juice has the power to prevent decomposition, or to arrest it 
after it has begun ; but disease alters these conditions, and food in the 
stomach may pass through various kinds of fermentation according to 
its composition — the starchy and saccharine undergoing the acetic, and 
the fatty, the butyric fermentation. In hasty eating much air may be 
swallowed — the oxygen is absorbed, and nitrogen and carbonic-acid 
gas remain. Although formerly denied, it is now admitted that, under 
some circumstances, air is secreted by the mucous membrane — in cer- 
tain states of the nervous system, especially. A small quantity of starch 
or sugar may produce a large volume of carbonic acid, causing great 
distention, and eructations of a sour liquid (pyrosis). Butyric acid 
induces a strong sense of heat and burning, gaseous eructations, often 
highly offensive from the presence of sulphur-compounds with hydro- 
gen. Furthermore, gaseous distention of the stomach affects the mus- 
cular movements of the organ, so that the foods are not properly dis- 
tributed and mixed with the gastric juice. In the regurgitations that 
ensue, particles of food are brought up, the nature of which is recog- 
nized by the patient ; it may be acid, bitter, or merely mawkish. 
Again, by the distention of the stomach, the heart is pushed up and 
its actions hampered, and, through the intimate nervous communica- 
tions, palpitation and intermittent pulse and a strongly accentuated 
second sound are produced. In consequence of the compression of 
the great venous trunks the return of blood from the head is impeded, 
and hence the face has a congested, red, and swollen appearance, and 
the head feels full, and headache and vertigo are present during the 
time the stomach digestion is going on. In some cases of chronic 
catarrh, vomiting of food occurs soon after it is swallowed. Later, if 
vomiting take place, the food is in various stages of digestion, and 
the vomited matters are highly offensive from the presence of butyric 
acid and the sulphur-compounds mentioned above. Sometimes the 
vomited matters will have a pasty or yeast-like appearance, due to the 



36 



DISEASES OF THE DIGESTIVE SYSTEM. 



presence of a peculiar fungus — from its fancied resemblance to a wool- 
pack called sarcina ventriculi. Vomiting is not constant nor regular, 
and in many cases occurs only when improper food has been taken. 
On the other hand, morning vomiting of topers is a constant and 
ordinary condition in these subjects. As soon as they arise in the 
morning a feeling of qualmishness comes on, and they strain a great 
deal to bring up some acid, glairy, tough mucus, or a quantity of 
rather thin, frothy, watery fluid mixed with air, and alkaline or neu- 
tral in reaction, and consisting chiefly of saliva swallowed during 
sleep. The appetite is usually diminished, or it may be capricious, 
and rarely excessive (bulimia). Usually but little food in the stom- 
ach develops a sense of satiety. Certain kinds of food, by the mere 
sight or remembrance of them, excite disgust and nausea ; and, as a 
rule, the animal foods are disliked, and acid fruits and fresh vegetables 
are craved. The saliva is usually increased in amount ; the tongue is 
pointed, red at the tip and edges, and the mucous membrane is glazed ; 
the large papillae at the base are swollen and tumefied, and there is 
present more or less follicular pharyngitis. The intestinal functions 
rarely continue undisturbed ; constipation and flatulence are usually 
present, and the constipation alternates with diarrhoea. An extension 
of the catarrhal process from the duodenum to the ductus communis 
and the smaller ducts causes more or less swelling and obstruction 
and, consequently, jaundice. The nutrition of the body is impaired 
by chronic gastric catarrh ; the strength is lessened, and the subcuta- 
neous fat diminishes ; the muscles lose in volume and decline in power, 
and the various functions are performed with less energy and efiiciency. 
This depression in the functions is especially marked in the psychical 
sphere, where it manifests itself in melancholy and hypochondria, the 
patient being solely occupied with his own miseries, and especially 
with those sensations and feelings belonging to his own state. The 
peculiar troubles of this mental state are enhanced by the headache, 
the vertigo, and the other cerebral symptoms which accompany stom- 
achal diseases. 

Diagnosis. — The coexistence of the cerebral symptoms just men- 
tioned with those of chronic gastric catarrh may greatly embarrass 
the diagnosis, but usually the differentiation may be made by refer- 
ence to the history of the case, the extended duration of the gastric 
symptoms, which is incompatible with the fact of a cerebral malady, 
and the absence of concomitant evidences of disease of the nervous 
centers. Ulcer of the stomach may be confounded with chronic gas- 
tric catarrh, but the diagnosis may be made by attention to the fol- 
lowing points : In ulcer, there is in front a fixed point of pain, poste- 
riorly a corresponding painful spot ; there is no diffused soreness ; 
there is acute pain as well as soreness ; the pain is aggravated by press- 



CHRONIC GASTRIC CATARRH. 



37 



nre, by the ingestion of solids and liquids, especially if hot or cold ; 
there is vomiting of blood. In cancer, there is pain, acute or lancinat- 
ing or burning, when the stomach is empty or full ; vomiting of food, 
of glairy mucus tinged with blood, and vomiting of black blood; 
rapid and continuous emaciation ; a peculiar icteroid, earthy hue ; a 
tumor, hard or w^ith nodosities ; enlargement of external glands (the 
sub-clavicular). 

Course and Duration. — The duration of chronic gastric catarrh is 
very variable ; it may last months or years, now better, now worse, 
depending on the measures, or the neglect of them, employed for 
relief. Readily enough cured, if the patient will submit to the regi- 
men necessary, it becomes exceedingly difficult if the causes which 
produced it continue in operation. Catarrh may terminate in ulcer, or 
it may lead to stenosis of the pylorus. 

Treatment. — The treatment of chronic gastric catarrh due to he- 
patic obstruction, to valvular disease of the heart, and to albuminuria, 
belongs to the management of these diseases respectively, and need 
not be considered here. 

Regulation of the diet is of the first consequence in all stomach 
diseases. All articles that disagree, whether owing to their nature or 
to idiosyncrasy, should be omitted. As acetic- and butyric-acid fer- 
mentations play so important a part in stomach derangements, it is 
highly important to exclude from the diet those substances the decom- 
position of which results in the formation of these acids. These arti- 
cles of diet are the saccharine, the starchy, and the fatty. The mucus 
acts as a ferment, and these decomposing substances enact the same 
r6le^ so that, when the starches, sugars, and fats reach the stomach, the 
fermentation begins. To exclude these articles, then, is the first step 
toward a cure. In lieu of these components of the diet, so important 
to most persons, the succulent vegetables, as lettuce, celery, spinach, 
cauliflower, tomatoes, etc., should be substituted. The materials for 
continuing the fermentations, consisting of mucus and the remains of 
previous fermentation, must be removed from the cavity if a continu- 
ance of the disorder is to be prevented. This can be accomplished 
in several ways : by the use of an absolute diet until the organ has 
freed itself of its decomposing contents ; by the administration of 
emetics and laxatives ; by washing out the organ with the stomach- 
pump ; and, lastly, by the employment of certain medicines. A curative 
measure of the highest importance is the "skim-milk cure." This con- 
sists in the exclusive use of milk for food until the stomach is freed 
from the materials of fermentation, and has had sufficient rest to re- 
cover. The milk is taken in the quantity of four ounces (about) every 
three hours, day and night, w^hen awake, and for a period of time de- 
termined by the cessation of the symptoms for which it was prescribed. 



38 



DISEASES OF THE DIGESTIVE SYSTEM. 



During this time nothing whatever is swallowed, except a laxative to 
relieve the constipation, or medicine for other purposes ; but no medi- 
cines should be administered during a course of the milk-cure, unless 
imperatively demanded. When, after a few weeks, or a month or two, 
the symptoms of gastric catarrh have subsided, then some additions to 
the diet may be made, very gradually, consisting at first of a little 
stale white bread, then rice, then a soft-boiled egg, and so on, gradu- 
ally, until a suitable diet is constructed. 

An emetic, occasionally, is highly useful to empty the stomach of 
decomposing materials, and to prepare a clean surface for the action 
of medicaments. Saline laxatives may be employed for the same pur- 
pose. An occasional Seidlitz powder ; now and then a drachm or two 
of Epsom salts in the early morning, or the Saratoga waters, or Piillna, 
or Friedrichshall, etc., are appropriate for this purpose. When there 
is much biliary derangement, phosphate of soda is highly serviceable. 
Still more effective for cleansing the stomach is the stomach-pump, 
or the fountain-syringe used as a siphon. With this instrument the 
cavity may be thoroughly washed out with tepid water, solution of 
common salt, solution of potassic chlorate, solution of salicylic acid, 
etc. As the effects are mechanical, chiefly, and are due to mere 
washing of the mucous membrane, it usually suffices to employ 
warm water. In severe cases the irrigation of the stomach may be 
practiced daily. This manoeuvre is readily executed by the use of 
Debove's tube — a flexible rubber tube about five feet in length, 
three eighths of an inch in diameter, and having an expanded bell- 
shaped orifice, into w^hich, as into a funnel, fluids can be poured. 
This tube has a distinct mark, nineteen inches from its distal extrem- 
ity, to indicate the distance from the teeth to the cavity of the stom- 
ach. As the tube is passed into the oesophagus, the patient is told 
to swallow repeatedly. When the stomach is reached the fluid in- 
tended for irrigation is poured into the tube, the orifice held well up 
until the organ is full, when the tube is turned downward and made 
to act as a siphon. 

Arsenic is a remedy of the first importance in the treatment of ca- 
tarrh of the stomach. It is best administered in the form of Fowler's 
solution, one or two drops three times a day before meals, and it should 
be continued for a month or more. Next to arsenic, the oxide of silver 
is to be commended, in pill form, one half to one grain, three times a 
day, also administered on an empty stomach ; but, as argyria may fol- 
low its prolonged use, it should not be given for a longer time than one 
month. When there is much acidity, it may be checked by the min- 
eral acids, notably the muriatic, given before meals. This practice is 
based on the principle that acids before meals prevent the outward dif- 
fusion of those constituents of the blood which contribute to form 



ATONIC DYSPEPSIA. 



39 



the acid gastric juice. Alkalies, although they afford relief, do not 
effect a cure, except in those cases of acidity of a temporary character 
due to fermentation of starchy and saccharine food, and accompanied 
by catarrh of the bile-ducts, and then the alkali most effective is the 
phosphate of soda. When acid is deficient, good results may be ob- 
tained by the use of alkalies before meals, on the well-recognized 
principle that an alkaline fluid in the stomach will favor the diffusion 
from the blood of its acid-forming constituents. When abnormal 
fermentations constitute the chief or only source of discomfort, the 
most serviceable remedy is carbolic acid, alone or in combination with 
bismuth. Gaseous eructations are best relieved by the same means. 
Freshly-burned charcoal, finely divided, is a good remedy, though only 
palliative, acting merely as an absorbent. After suitable treatment 
for the relief of the local condition, tincture of nux vomica is an ex- 
cellent stomachic, especially adapted to the chronic catarrh of spirit- 
drinkers. The bitters in general, with or without the mineral acids, 
are applicable under the same conditions. It should never be forgot- 
ten that all special stimulants to the gastric mucous membrane are 
injurious, and should never be employed until the morbid state is re- 
moved. To employ them without proper regulation of the diet is 
simply to add another source of irritation. It can not be too strongly 
impressed on the reader that rest, which is essential to the treatment 
of any diseased organ, is equally necessary to the stomach when it is 
suffering ; but, as some aliment is absolutely necessary to life, the 
stomach can never be put into a state of complete repose. Hence the 
need of a most careful regulation of the diet, so that the condition of 
rest may be, as nearly as possible, attained. Alimentation by the rec- 
tum is a precious resource under these circumstances. Finely-powdered 
beef, meat-extracts, peptonized foods, eggs, etc., to which the digestive 
ferments are added, can be administered by the rectum. Defibrinated 
blood is, no doubt, in the greatest proportion of cases, the most valu- 
able aliment for rectal use.* 



ATONIC DYSPEPSIA. 

Definition. — By atonic dyspepsia is meant a form of indigestion 
due to a depressed state of the stomach. It is that form of functional 
derangement usually called dyspepsia. 

Causes. — It is often inherited. It is a disease of advanced life, 
and is then accompanied by those senile changes belonging to that 
period, and is a consequence of them. It is a symptom in depressed 

* Full particulars are given in the author's " Treatise on Materia Medica and Thera- 
peutics," fifth edition. 



40 



DISEASES OF THE DIGESTIVE SYSTEM. 



states of the system generally, as, for example, in exhausting dis- 
charges, as haemorrhages, leucorrhoea, profuse suppuration, etc. It is 
produced by all those circumstances comprehended under the term 
bad hygiene. The most influential factors are improper and excessive 
alimentation, and severe mental and physical exertion immediately 
after eating. 

Morbid Anatomy. — This malady has not, properly speaking, a mor- 
bid anatomy : besides aniemia and deficient secretion, there are no 
changes. Various alterations have been noted, as atrophy of the tu- 
bules, fatty degeneration, increase of the connective tissue, etc. But 
these changes belong to other states, of which atonic dyspepsia is 
merely a symptom. 

Symptoms. — A sense of weight and uneasiness, lasting throughout 
the process of digestion, suspended for a short period when food is 
taken, is usually the initial symptom. A feeling as if a foreign body 
were lodged behind the sternum, or higher up in the oesophagus, often 
with a sense of oppression or dyspnoea, is frequently experienced. 
Acute pain is rarely felt, but there is usually some flatulent colic, and 
pressure fails to develop pain, but rather affords relief to uneasy sen- 
sations. Digestion is impaired in respect to all classes of foods, fari- 
naceous, saccharine, and fatty ; and hence, during the process of diges- 
tion, flatulence from the formation of carbonic acid and eructation of 
rancid fats are frequently present. More or less intestinal disturbance 
accompanies the stomach symptoms, and constipation almost always 
occurs. The appetite is usually feeble, and the disinclination for food 
includes all the varieties. There is little thirst, and the ingestion of 
fluid gives rise to distress. The tongue is too large, and is marked 
along its borders by the teeth, and is at the same time pale and 
flabby. The mucous membrane of the mouth is also pale and the 
gums are soft and spongy ; the tonsils are apt to be enlarged, the 
uvula relaxed, the voice husky, and there is frequent clearing of the 
throat. The bodily condition generally is that of depression ; the 
pulse is weak, excitable, and easily compressed ; palpitation occurs 
quickly on exertion and frequently without effort of any kind ; inter- 
mission of the pulse-beat is by no means uncommon, and attacks of 
pseudo angina pectoris take place, and they may have an alarming 
character, especially in persons after middle age affected with degen- 
erative changes in the vascular system. Flatulent distention of the 
abdomen induces oppression of the chest, but dyspnoea may occur 
without such cause, being due to a nervous state. The skin is usu- 
ally pallid and earthy, moist and clammy, and the extremities cold. 
The urine is pale, of low specific gravity, and loaded with the phos- 
phates. The mental condition is in harmony with the general state 
— that is, depressed. There is great inaptitude for mental exertion, 



GASTRALGIA. 



41 



an impaired state of the memory and attention, and irritability of 
temper. Drowsiness supervenes after eating, while sleep at night is 
restless and unrefreshing. 

Diag^nosis. — Atonic dyspepsia differs from chronic gastric catarrh 
in respect to the amount of pain, vomiting, and tenderness on press- 
ure, which are less, and the depression which is greater, in the former 
than in the latter. 

Treatment. — In this as in other stomach disorders, the first step con- 
sists in regulation of the diet. It is useful to commence the dietetic 
management by the milk-cure. Next, as rapidly as possible, nutritious 
but easily digested articles must be added. As the digestive powers 
are feeble, food must be given in small quantity but frequently. As 
the foods disagree, irrespective of their quality, obviously quantity 
and frequency of ingestion are the points to be considered. As the 
powers of digestion are depressed, the special aids to this function are 
indicated : pepsin, lacto-pepsin, in combination with muriatic acid ; 
pepsin and bismuth with aromatic powder ; tincture of nux vomica, 
strychnine, and the bitters, especially calumba, with or without muriatic 
acid ; the mild chalybeates, as massa ferri carb., the citrate, malate, or 
tartrate of iron, etc., are the most appropriate of the medicinal agents. 
A small quantity of acid wine at dinner is a good stimulant to the 
digestive function. A moderate dose of whisky, taken before meals, 
is a capital remedy to promote the appetite and the digestion ; but it 
is a dangerous remedy, for it so overcomes the feeling of depression 
as to be very grateful, and there is therefore a constant temptation to 
repeat the dose. As, in these cases, there is usually more or less men- 
tal depression, change of scene, travel, and agreeable occupation, con- 
tribute materially to the cure. 



GASTRALGIA. 

Definition. — Gastralgia is a painful state of the sensory nerves of 
the stomach, induced by various sources of irritation, and free from 
fever. 

Causes, — Doubtless the chief factor is a peculiar state of the 
nervous system, the neurotic temperament, so called, or the nerv- 
ous state or hysteria. This condition of the nerves existing, va- 
rious substances, which under ordinary circumstances would not 
excite the least distress, now cause severe pain. It is highly probable 
that the abuse of tea and coffee has no little influence in causing the 
disease. 

Symptoms. — The characteristic symptom of gastralgia is the occur- 
rence of severe paroxysmal pain, felt in greatest intensity at or about 



42 



DISEASES OF THE DIGESTIVE SYSTEM. 



the epigastrium, and radiating thence upward over the chest and down- 
ward through the abdomen. The pain also is felt in the back, and 
seems to pierce through the body, and it shoots upward to the shoul- 
ders. The pain is not increased but diminished by pressure, and the 
patient instinctively lies or presses firmly on the abdomen, or demands 
to be rubbed or beaten on the back. In the severest cases, the pain is 
so excessive as to produce profound prostration ; the pulse is small, 
rapid, and weak, the surface is cold and covered with a cold sweat, 
and the features are shrunken. In almost all cases, the action of the 
heart is disturbed, owing to the intimate nervous communications be- 
tween the two organs ; the pulse is small and weak or intermitting. 
The duration of the attacks is very variable, lasting for a few hours, 
for a day or two, or continuing for months with intermissions or 
remissions. Usually the attacks are of short duration, and terminate 
with eructations of gas, with vomiting, or the more acute pain subsides, 
leaving a sense of soreness, and occasional lighter 23ains, which may 
continue for several days. The attacks may be regularly intermittent, 
in cases of uterine disease, and when caused by malaria. During the 
interval, the function of digestion may proceed undisturbed, and the 
nutrition of the body continue at the normal. Various disorders of 
the nervous system are usually present, as — palpitations, migraine, 
hysterical phenomena, notably the globus, etc. In males, hypochon- 
dria, associated with oxaluria, is not infrequent. 

Course and Duration. — Gastralgia is an essentially chronic malady, 
in that the attacks are prone to return from time to time, and the as- 
sociated disorders continue in the interim to plague the patient. Those 
cases dependent on malaria, or on the presence of indigestible food, 
may be cured with comparative facility, but the ordinary cases are not 
readily cured. Notwithstanding the obstinacy of these cases, gastral- 
gia is not dangerous to life. 

Diagnosis. — Gastralgia is to be differentiated from myalgia affect- 
ing the abdominal muscles, intercostal neuralgia, hepatalgia, neuralgia 
of the solar plexus, ulcer of the stomach, and cancer. In myalgia the 
pain is restricted to the affected muscles, and has not the acute and 
lancinating character of gastralgia, and is unaccompanied by nausea 
and vomiting. As respects intercostal neuralgia, it is to be noted that 
the pain is in the left hypochondrium, that painful points can be de- 
veloped by pressure in the course of the nerve-trunk, and at the spine, 
and that this affection is unaccompanied by nausea and vomiting. To 
separate gastralgia from neuralgia of the solar plexus is in some cases 
extremely difficult ; but attention to the following points may prevent 
error : in gastralgia, there is a history of previous stomachal disorders ; 
in neuralgia of the solar plexus, the inhibition of the heart's action is 
greater, and the systemic depression is more profound. Hepatalgia 



GASTRALGIA. 



43 



and hepatic colic are to be separated by the situation of the pain in the 
right hypochondrium, by the tenderness in the region of the gall- 
bladder, by the symptomatic fever, and by the jaundice. From 
cancer, gastralgia is differentiated by the age of the subject, by the 
character of the vomited matters, the persistence of the pain, the 
cachexia, the emaciation, and the tumor ; from ulcer, by the fixed- 
ness of the pain, its constant presence with soreness, the vomiting of 
blood, etc. 

Treatment. — During a paroxysm, the first point is the relief of 
pain. This may be most effectively and promptly accomplished by 
the hypodermatic injection of morphine, and frequently so small a dose 
as one twelfth of a grain suffices. As there is always danger of opium- 
habit in these cases, this fascinating remedy must be used with cau- 
tion. Opium or morphine is frequently prescribed with bismuth and 
aromatic powder. Morphine is also used endermically — that is, applied 
to a blistered surface, about a square inch of the skin being denuded. 
By enema is an efficient mode of administering the anodyne. When, 
from any cause, morphine can not be given, the pain, as also the nausea 
and vomiting, may be arrested by creosote or carbolic acid. This 
remedy may also be administered with bismuth in an emulsion — a 
combination of the most efficient kind. Equal parts of tincture of 
iodine and carbolic acid, of which a drop may be administered every 
hour in a little cold water, is a most valuable agent, not only for the 
relief of pain, but to stop the vomiting. In many cases nitro-glycerin 
has an excellent effect. The centesimal solution is the most approjmate 
form for administration — one drop every half -hour being given until 
relief or the characteristic elfects are produced. Arsenic (one drop of 
Fowler's solution) and opium (two to five drops of the tincture) are 
not unfrequently highly serviceable for the relief of the paroxysms, but 
they are more generally useful for the accompanying condition of the 
mucous membrane, and the end organs of the nerves of the stomach. 
There is no remedy so constantly curative of the local causes of the 
attacks, and so efficient in preventing their return, as arsenic. For 
the condition of things between the attacks, next to arsenic, stand the 
oxide and nitrate of silver. For the strictly intermittent cases, occur- 
ring at a fixed hour, quinine is invaluable ; but the author has seen 
cases which were not removed by quinine, but ceased promptly when 
salicylic acid was administered. When attacks of gastralgia are due 
to indigestible food, the first duty is to empty the stomach. If vomit- 
ing is going on, it may be encouraged by large draughts of warm 
water ; if vomiting has not occurred, it should be induced by an 
emetic, preferably by apomorphine administered hypodermatically, to 
avoid irritation of the stomach. If acid and fermenting materials 
remain to keep up the disturbance, they should be removed by irri- 



DISEASES OF THE DIGESTIVE SYSTEM. 



gation of the stomach, or by mild laxatives of the saline and antacid 
character. It is generally better to remove the contents of the stom- 
ach before administering anodynes. The subjects of gastralgia are 
usually of the nervous, hysterical, and hypochondriacal type, and 
require chalybeate and supporting remedies. As the stomach in 
such subjects is easily offended, only the milder preparations of iron 
can be given — such as the carbonate, the citrate, lactate, etc. ; but, 
in some persons of a habit feeble and relaxed, the more astringent 
preparations do better — for example, the sulphate and the chloride. 
Excellent results are often obtained from the use of the mineral 
acids, notably the muriate, and especially when administered con- 
jointly with the tincture of nux vomica (Fox), The long-continued 
use of arsenic in a small dose — one drop ter in die of Fowler's solu- 
tion — is more effective, according to the author's experience, than 
any remedy mentioned. As attacks of gastralgia are, very frequently 
at least, excited by indigestible food, it is highly important to regu- 
late the diet. Furthermore, in these subjects the digestion has been 
enfeebled by the depressed state of the nervous system. The best 
results are therefore obtained by a careful regulation of the hours 
of eating, the quality of the food, and the mental and bodily exer- 
cise. In most cases, probably, the treatment should be begun by the 
milk-cure, and subsequently a dietary should be constructed suit- 
able to the needs of individual cases. In some instances, the frequent 
use of a small amount of food is more serviceable than the taking 
of ordinary meals. When the digestion is feeble merely, pepsin 
and lactic or muriatic acids are most useful. When acidity and 
heartburn exist, due to the fermentation of the starches and sugars, 
the mineral acids must not be given after meals, but before, for 
chemical reasons already explained. 



ULCER OF THE STOMACH. 

Definition. — By the term ulcer is meant a solution of continuity 
involving the mucous membrane and one or more of the layers of 
which the wall of the stomach is composed, with defined margins 
having a greater thickness than the adjacent healthy tissues. Symp- 
tomatically, the stomach-ulcer is characterized by pain, disorders of 
digestion, and vomiting of blood. 

Causes. — Ulcer of the stomach is a comparatively common disease, 
and is found to exist in five per cent, of the deaths from all causes. 
It is present in proportionately greater numbers after thirty-five, be- 
cause it is an essentially chronic malady ; but it is, really, more fre- 
quent in youth and middle life, from fifteen to thirty, and it is com- 
paratively often seen in housemaids of twenty — an age, too, at which 



ULCER OF THE STOMACH. 



45 



rupture occurs in greater proportion than at any other. It is probable 
also that women are more subject to the disease than men, and that 
rupture occurs more frequently in the former than in the latter. The 
most influential factors in its pathogeny are, variation in the tonus of 
the gastric vessels and mechanical arrest of the circulation at the 
point where the ulcer forms (thrombosis, embolism). There is usu- 
ally, in these cases, disease of the arterial tunics (atheroma and endar- 
teritis), which finally causes coagulation of the blood and arrest of the 
blood-stream in a nutritious artery ; obstruction of the portal circula- 
tion may induce thrombosis, hsemorrhagic infiltration, etc. The result 
of a sudden and severe diminution in the amount of blood passing to 
a part, or of its entire arrest, is to diminish the alkalescence of the 
deeper layers of the mucous membrane, and to permit the corrosive 
and solvent action of the gastric juice. It has long been recognized 
that amenorrhoea, anaemia, chlorosis, the puerperal state, prolonged 
lactation, and tuberculosis, are also etiological factors, and probably 
because, in these states, a necrotic process is readily induced, under 
favorable local conditions. 

Irritation of certain parts of the brain is followed by ecchymoses 
and erosions of the mucous membrane of the stomach. Burns of the 
chest and abdomen sometimes cause ulceration of the duodenum. A 
peculiar state of the nervous system must, therefore, be regarded as 
one of the causes of this disease. 

Pathological Anatomy. — Ulcers con-esponding in every respect to 
those of the stomach are found rarely at the lower part of the oesopha- 
gus, at the first part of the duodenum (associated with burns on the 
surface ?), and in the caecum, as the author has shown. In twenty per 
cent, of the cases of stomach-ulcer, they are multiple, but rarely as 
many as five existing at one time ; in eighty per cent, of the cases, 
the ulcer is solitary. Xot all parts of the stomach are equally liable 
to the ulcerative process. In four fifths of all cases the ulcer or 
ulcers are found on the posterior wall, the lesser curvature, and about 
the pylorus. In size they vary greatly, according to age, and prob- 
ably, according to their nature ; but they are not smaller than a dime, 
and never attain greater dimensions than six inches by three. In 
shape they are round or oval, more frequently round. So great is the 
difference in size, quality, and appearance between the so-called acute 
perforating ulcer and the round, indurated, and chronic ulcer, that it 
is diflicult to realize that they are merely stages of the same process. 
The former is about the size of a dime, or shilling-piece, is round and 
has smooth edges without induration and increased thickness, fre- 
quently covered with a clot or containing a mass of slough adherent, 
and extending in depth to the submucous connective tissue. Ulcers 
of this description are usually found in young subjects — housemaids 
notably — have a great tendency to perforate, and are not unfrequently 



46 



DISEASES OF THE DIGESTIVE SYSTEM. 



produced hy obstruction to the portal circulation (haemorrliagic erosion, 
thrombosis, etc.). The latter or chronic form is large in size, having 
walls of great thickness and indurated, composed of connective and 
granulation tissue deposited at various times, giving to it a stratified 
appearance. After many years, such an ulcer presents a crater-like 
aspect, with shelving sides, and terminates by a small apex in muscular, 
sub-muscular, or peritoneal layer, or in a perforation. The connective 
and granulation tissue, of which the crater-like internal surface is com- 
posed, is also deposited at the base, and in this way perforation may 
be prevented. Facts are wanting to demonstrate an intermediate or 
transition stage between the two forms of stomach - ulcer. In the 
course of development of the chronic ulcer, the anatomical elements of 
the mucous membrane, including the tubular glands, are destroyed, 
and in rare instances villous or polypoid growths appear in the neigh- 
borhood of the new formation. In very rare instances the mucous 
membrane may be largely preserved, and the ulcerative action exca- 
vate a cavity beneath. Several small ulcers may coalesce, unite in their 
long diameters, and thus form an oval excavation along the lesser 
curvature, or make a girdle around the pylorus. Ulcers of the stomach 
tend to spontaneous cure. In many instances of death from other 
causes, ulcers, either healing or cicatrized, have been found when no 
symptoms had existed during life, in any sense indicative of their 
presence. In the process of cicatrization, if the ulceration has not 
extended beyond the muscular layer, the repair is by union of 
granulations, and the cicatrix forms a puckered depression. When 
there is more extensive loss of substance, involving all but the perito- 
neal layer, there is very great contraction, and a large cicatrix with 
radiating lines of thickened connective tissue remains. The peritoneal 
surface is drawn in, giving to that membrane a puckered appearance. 
If the ulcer had been large, oblong, and formed by the coalescence of 
several smaller ulcers, and situated near the pylorus, narrowing of that 
orifice, and consequent dilatation of the rest of the organ, were neces- 
sary results. Sometimes the base of the ulcer forms adhesions to 
neighboring organs in the process of cicatrization, causing ever after- 
ward serious interference with the movements of the stomach, and 
therefore impairing its functions. Secondary cavities are, occasion- 
ally, formed by a local peritonitis arising from perforation, the con- 
tents of the stomach being prevented escaping into the general cavity 
of the peritonieum by a limiting inflammation which secures firm ad- 
hesion to neighboring organs, to the omentum, pancreas, liver, the 
adjacent lymphatics, the transverse colon, the kidneys, the diaphragm, 
and the abdominal walls. If cicatrization take place after these 
attachments have formed to adjacent organs, they are embraced in the 
cicatricial tissue, and very great deformity, with serious impairment 
of function, result. Unfortunately, these conservative adhesions are 



ULCER OF THE STOMACH. 



47 



not always formed : the ulcerative action may continue, cavities be 
created in the manner already indicated, or communications be estab- 
lished between the stomach and colon, or a fistulous sinus be made 
through the walls of the abdomen externally, or the diaphragm be per- 
forated and the thoracic cavity entered. When perforation takes 
place, there being no limiting inflammation, nor adhesion to adjacent 
viscera, the contents of the stomach are suddenly precipitated into the 
general cavity of the abdomen, exciting general peritonitis. Ulcers 
situated on the anterior wall of the stomach are specially exposed to 
this danger, since in that situation adhesions can not easily be formed. 
The larger vessels of the stomach being deeply placed, escape the 
eroding action of the ulcer, unless the ulceration has proceeded deeply, 
nearly to the point of perforation. Furthermore, in the process of 
extension of the ulceration, the vessels resist longer, and become 
occluded, before yielding to the erosion. Now and then, arterial twigs 
are entered by a slough, or veins about the ulcer, which have become 
varicose, as is frequently the case, are destroyed by a superficial ulcer- 
ation. Relapses are comparatively frequent. The cicatricial tissue, 
having low vitality, ulcerates from slight causes. 

Changes, which have apparently some relation to the morbid pro- 
cess in the stomach, occur in other organs. It is clear, however, that 
certain diseases of the arterial system, as endocarditis, endarteritis, 
have an immediate connection, for embolism and thrombosis are impor- 
tant factors in the pathogeny of ulcer. In about one half of the cases, 
there is coincident pulmonary disease, very often tuberculosis. It is a 
popular notion that stomach-ulcers are transformed into cancer ; it is 
true that cancer sometimes develops at the site of an old ulcer. 

Symptoms. — There are three important symptoms of stomach-ulcer 
— pain, indigestion, and vomiting (h^ematemesis). It should be known 
that some very acute cases occur without symptoms. In apparently per- 
fect health, an individual has a ^perforation of the walls of the stomach ; 
an acute peritonitis is immediately lighted up ; intense pain, vomiting 
of blood, and profound prostration occur, and death takes place in a 
few hours or in a day or two. The author has met with such a case. 
More usually ulcer of the stomach is a chronic malady and character- 
ized by the existence for many months or years of the three symptoms 
mentioned. Although the pain varies in intensity and differs much in 
different cases, yet, on the whole, there is remarkable correspondence. 
In the largest number of cases the pain is felt in front, in or just below 
the xiphoid appendix ; or in the left hypochondrium in the intercostal 
space between the sixth and seventh rib, occasionally ; more frequent- 
ly above the umbilicus, in the neighborhood of the pylorus. Posteri- 
orly, and this position is even more important, the pain is felt in the 
region of the last dorsal or first lumbar vertebra, or under the angle of 
the scapula. The pain in front and behind seems to be continuous, as 



48 



DISEASES OF THE DIGESTIVE SYSTEM. 



if it passed directly through the body. This is its distinctive charac- 
ter — a fixed, gnawing, burning pain, boring through from front to 
back, and occupying a space which the finger may cover. More or 
less pain radiates from this central and fixed pain, and is felt in the 
chest behind the sternum, in the intercostal nerves, in the cervico- 
brachial plexus, etc. Very great tenderness is experienced on pressure 
over the vertebra behind and the seat of pain in front. Corsets or a 
tight dress can not be borne, and, in sitting, the patient seeks a posi- 
tion more or less bent, to avoid the pressure of internal organs against 
the sore spot. 

Besides these, already described, the patient suffers with attacks of 
gastralgia, sometimes of extreme violence, but they do not occur with 
any regularity. When the gastralgia comes on, the fixed pain is in- 
creased in severity, and pain of extraordinary violence radiates through 
the abdomen and chest. During these paroxysms, the action of the 
heart becomes very feeble, and the vital forces much depressed. An 
alarming syncope, or general convulsions, may ensue if the patient pos- 
sess a highly sensitive reflex organization. As the attacks are usually 
due to the presence of indigestible food, they cease when the stomach 
is empty ; but they also arise from cold, fatigue, mental and moral 
emotion — to the causes, indeed, of neuralgia elsewhere. The pain of 
stomach-ulcer — the fixed pain— is increased by taking food. In a ma- 
jority of cases the increase of pain is experienced as soon as food enters 
the stomach ; in a smaller proportion the exacerbation occurs in from 
fifteen minutes to a half hour ; in others, the most severe suffering 
takes place when food is supposed to be passing through the pylorus, 
in about three hours after eating. The character of the food influ- 
ences the production of pain— indigestible, especially irritating, arti- 
cles causing greater suffering than bland articles. The increase of 
pain persists until the food is rejected by vomiting or passes the 
pyloric orifice. The pain caused by the presence of food in the stom- 
ach should not be confounded with the attacks of gastralgia, which 
may arise from hygienic and moral causes as well as improper food. 
Some cases of stomach-ulcer are free from distress of any kind ; in 
fact, they continue for months and years with no more local disturb- 
ance than is produced by chronic gastric catarrh ; but these must be 
regarded as exceptional. Vomiting is a frequent but not an in\ari- 
able symptom ; in a few instances it never occurs ; in others it comes 
on late in the course of the disease. The vomiting is preceded and 
accompanied by pain, but, when the stomach is emptied, the pain 
ceases. Occasionally attacks of vomiting and pain occur when the 
stomach is empty ; some glairy mucus, with or without blood, only, 
coming up with a good deal of straining, showing that the disturbance 
of the stomach is not due merely to the presence of food. If the vom- 
iting persist, and there be much retching, some bilious matter may 



ULCER or THE STOMACH. 



49 



finally be brought up. But the great factor is unquestionably food, 
and especially undigested food ; but more or less gastric catarrh is a 
constant element in cases of ulcer of the stomach. The time when the 
vomiting occurs may indicate the position of the ulcer. If the inges- 
tion of food is followed immediately by pain, the ulcer is probably in 
the vicinage of the cardia. If situated in the greater curvature, there 
may be but little vomiting, and that will take place in about an hour 
after food ; when near the pylorus, vomiting is an invariable symp- 
tom, and the pain is great, but the pain and vomiting do not come on 
until two or three hours. It must be admitted that these statements 
as to the time of the vomiting and the position of the ulcer are only 
approximately correct. Vomiting of blood is the most characteristic 
single symptom, but is not pathognomonic. It is absent in about one 
third of the cases. Hgematemesis may occur only at the monthly 
period as a vicarious discharge, or merely as an accompaniment of the 
regular flow. Pain coming on after eating, vomiting of food mixed 
with blood, and then of blood only, is an extremely significant combi- 
nation of symptoms. The vomited matter may consist only of blood, 
red or brownish red, when it comes up immediately ; if retained for a 
short time, it appears in clots more or less blackish if acted on by the 
stomach- juices. When held in the stomach for some time, and the 
amount is small, it may present the well-known " coffee-ground " ap- 
pearance ; but if the quantity is large, and has been acted on by the 
gastric juice, and churned up by the movements of the stomach, it 
will then have a brownish-black, uniformly granular, and homogeneous 
aspect. As the vomiting usually occurs quickly after the blood is 
poured out, the ordinary and characteristic appearance is that of red- 
dish blood partly coagulated. Coffee-grounds, blackish and brownish- 
black masses or particles, belong rather to cancer. The nutrition may 
or may not be impaired in gastric ulcer. The small perforating ulcer 
is often met with in young girls of rather full habit but lymphatic in 
type. The chronic ulcer of long standing, if small, may not affect the 
digestion sufficiently to lower the body-w^eight; but, if large, the diges- 
tion-space is so much abridged, that there must be a constant waste, 
which the primary assimilation is unable to supply. Much depends on 
the amount of loss by vomiting, and this is influenced somewhat by the 
inherent irritability of the stomach. The frequent recurrence of hsem- 
orrhage also seriously impairs the nutrition and induces a cachectic 
state and a peculiar tint of the skin, which may be confounded with 
the earthy hue of carcinoma. The tongue may be clean, somewhat 
furred, red at the tip and at the edges, fissured, but there is no charac- 
teristic appearance. As a rule, there is obstinate constipation. Amen- 
orrhoea is a frequent complication, due partly to the vicarious haemate- 
mesis and partly to the profound anaemia to which some patients are 
reduced. 



50 



DISEASES OF THE DIGESTIVE SYSTEM. 



Course and Duration. — The beliavior of the acute and perforating 
ulcer has been sufficiently discussed. The chronic and common form 
has a very variable duration. Well-authenticated cases have existed 
ten years — an example of which the author has had under observation. 
From three to five years is a comparatively common period of duration. 
The chief reasons for their long-continued existence are, their essen- 
tially chronic character and the frequent changes in their condition — 
now increasing, now improving, almost cicatrized, then a change in 
the constitutional state of the patient, or indiscretion in food will re- 
excite ulceration in tissue almost or entirely repaired. At various 
periods in the course of the chronic ulcer there may occur a chill fol- 
lowed by fever, exquisite tenderness of the epigastric and umbilical 
regions, nausea, vomiting, constipation, a quick, small pulse, etc., symp- 
toms of a local and limiting peritonitis. Some cases of chronic ulcer 
run an entirely latent course ; that is, there are no more pronounced 
symptoms than those of dyspepsia. 

Termination. — A large proportion terminate in recovery — complete 
cicatrization, without any subsequent impairment of the functions of 
the stomach. The cure may be partial ; there may be adhesions con- 
tracted to adjacent organs, which alter the shape and impair the mo- 
tions of the stomach ; contraction of the pyloric orifice, leading to dila- 
tation and gradual inanition. The ulcer may cause death in various 
ways : there may be a gradual failure from pain, vomiting of food, 
vomiting of blood, and by the growth of lesions in other organs (car- 
diac disease, tuberculosis, etc.). Death may occur by haemorrhage — 
according to Brinton five in one hundred so terminate. A consider- 
able proportion — 13*4 per cent. — die by perforation and consequent 
peritonitis. This unfortunate accident is announced by a sudden and 
great depression in the powers of life, and death by shock, or the 
prompt development of fatal peritonitis. 

Diagnosis. — Notwithstanding a diagnosis may be made with great 
certainty in cases presenting typical symptoms, it may be very difficult 
in other cases. The doubts may occur between ulcer and chronic 
gastric catarrh, gastralgia, hepatic colic, cancer, and chlorosis. In 
chronic gastric catarrh the pain after food is much less, and, in fact, 
in very many cases the distress is alleviated by taking food ; vomiting 
is occasional, and there is no vomiting of blood. The paroxysms of 
gastralgia may be the same as in ulcer, but the behavior of the two' 
diseases, otherwise, is very different. Gastralgia is in paroxysms en- 
tirely, and between them the patient suffers but little, and does not 
always have pain after eating, vomiting, and relief by the rejection of 
food and the vomiting of blood. In hepatic colic the pain radiates 
from the region of the gall-bladder, suddenly terminates when the cal- 
culus reaches the intestine, and is followed by jaundice. During the 
attack, owing to the congestion of the portal system, there may be 



ULCER OF THE STOMACH. 



51 



vomiting of blood, but it is never great in amount, and all the symp- 
toms subside in a few days, the patient being free from any disturb- 
ance of the stomach afterward. In cancer, the age of the subject, the 
emaciation and cachexia, the tumor and enlarged lymphatic glands, 
the vomiting of coffee-ground and blackish and brownish-black mate- 
rial, instead of the red or brownish-red blood in large amount in ulcer, 
are the most characteristic differences. It is more difficult to separate 
chlorosis with amenorrhoea from ulcer of the stomach, because these 
subjects have the distress after food, the vomiting, and vicarious men- 
struation by the stomach. Under these circumstances of inevitable 
doubt, it were better to decide by therapeutic means. The case may 
be treated as one of gastric ulcer by an absolute low diet ; if it is a 
case of ulcer, it will improve under this method ; if a case of chlorosis, 
it will get worse — then a resort to iron and mineral acids will bring 
about a decided change for the better. 

Prognosis. — Although the cure of ulcer may be confidently expected 
in favorable cases, yet such are the dangers from perforation and 
haemorrhage that the prognosis must be regarded as serious. When 
tuberculosis and endocardial lesions exist, the gravity of the case is 
correspondingly increased. 

Treatment. — The first and most important consideration is to give 
the stomach rest, which is accomplished by reducing the food taken to 
the minimum. An exclusive milk-diet accomplishes this object, while 
at the same time it contains the necessary alimentary principles for 
the support of the body. All rough, harsh, and coarse ingesta, such as 
oatmeal, brown-bread, and fruits, irritate the surface of the ulcer, and 
increase the existing ulceration, and retard healing. Starchy and sac- 
charine foods are objectionable because they ferment, producing acid 
which is very irritating to the ulcerated surface. Milk should be given 
systematically — one gill (four ounces) every three hours, day and night, 
during waking, and it acts better if taken hot, 110° to 115° F. If it 
cause a sensation of heaviness or uneasiness, nausea or vomiting, the 
addition of lime-water will enable it to be better borne. The meat 
solution so strongly advocated by Leube, or that of Valentine, can be 
substituted for milk, if the latter prove repugnant to the patient or 
can not for any reason be used. To aid in supporting the powers of 
life, rectal alimentation may be employed. Foster proposes to relieve 
the stomach entirely for a time, supporting the powers of life by rectal 
alimentation, since the healing process is greatly promoted by giving 
the organ some days of absolute rest. The discovery of the utility of 
defibrinated blood, as a means of rectal alimentation, made by Dr. 
Smith, of New York, has added much to our resources. The method 
consists simply in defibrinating the blood as soon as drawn at the 
shambles, and in injecting from three to six ounces morning and even- 
ing. If rectal alimentation is not employed exclusively, it should be 



52 



DISEASES OF THE DIGESTIVE SYSTEM. 



combined with the milk regimen — for, the richer the condition of the 
blood, the more rapidly and perfectly can repair take place. As the 
destruction of the mucous membrane was originally brought about by 
the solvent action of the gastric juice, and as the irritation caused by 
this is the chief obstacle to healing, it is important to diminish the 
acidity and to keep the surface of the ulcer clean. These purposes 
are now accomplished by mechanical means, by irrigation of the cavity 
of the stomach by the siphon or the stomach-pump, as the same pro- 
cess is employed in other stomach-diseases ; but caution is necessary 
in the use of the pump, lest the tube might cause a perforation. The 
same object may be accomplished by medicinal means — by the free 
use of the alkaline mineral waters. As regards the strictly medicinal 
remedies, the most important is arsenic in small doses, one to three 
drops of Fowler's solution three times a day. Next, named in the 
order of their relative importance, are oxide and nitrate of silver, in 
half-grain doses three times a day, and bismuth in fifteen-grain doses. 
If there be much pain, morphine in the hypodermatic mode ; but, if 
the alimentation is proper, pain will hardly require attention. The 
regimen advised should be pursued for several weeks, or until such 
improvement is manifest as to indicate that cicatrization is pretty well 
advanced, when the diet may be very carefully enlarged by the 
addition of rice, soft-boiled eggs, animal broth, etc. ; but the patient 
should be impressed with the importance of a simple dietary ever 
after. The accidents which arise should be treated according to their 
nature. If haemorrhage occur, ice should be applied to the epigas- 
trium, and pellets of ice should be swallowed ; ergotin should be 
injected subcutaneously, and solution of pernitrate or of chloride of 
iron should be administered by the stomach. If perforation have 
taken place, the most absolute rest must be enjoined, and the alimen- 
tation must be exclusively rectal. The remedy above all others is 
morphine by the skin, maintaining a decided effect. 

CARCINOMA OF THE STOMACH. 

Etiology. — The points of election for the development of cancer in 
the intestinal canal, named in the order of their relative frequency, are 
the stomach, the rectum, the caecum, the flexures of the colon. Of all 
the organs of the body, the stomach is most frequently the seat of 
cancer — more frequently than the uterus, which comes, strictly, next. 
As regards age, the majority of cases occur at fifty, but the disease 
may appear at any time from forty-five to sixty. It is very rare from 
thirty to forty. According to some authorities, cancer attacks the 
male sex by preference, but careful investigation shows that this view 
is erroneous, and that the two sexes are about equally affected. The 
well-to-do classes are said to be more liable to the disease than the 



CARCINOMA OF THE STOMACH. 



5a 



poor, and tlie obese, hearty feeders, rather than the abstemious, but 
these are doubtful propositions. 

Predisposition and heredity play an important part in the causation 
of cancer ; they are, doubtless, the most influential factors. The in- 
herited tendency may not be traced sometimes, when it exists, be- 
cause of the behavior of the cancer-germ, skipping over one or more 
generations and appearing in subsequent ones. All other presumed 
moral and dietetic causes are rather fanciful. 

Pathological Anatomy. — The forms of cancer occurring in the stom- 
ach are the following : scirrhus, or fibroid ; medullary, or encepha- 
loid ; and the gelatinous, or colloid. As regards the site, the points 
of election are in sixty per cent, at the pylorus ; in twenty per cent, at 
the lesser curvature ; and in ten per cent, at the cardia. In the pro- 
cess of growth, extension is more apt to be vertical than transverse ; 
but, when the growth is about the cardia or the pylorus, the new for- 
mation takes an annular direction, causing stenosis. 

The initial changes in the development of cancer of the stomach are 
an increased vascularity and the presence of numerous w^hite blood- 
corpuscles in the cylindrical epithelium of the gastric glands — as in 
ordinary inflammation — but the changes soon take a special direction 
and character. Rapid proliferation of the cells of the cylindrical epi- 
thelium occurs, and assumes a downward direction, penetrating the 
mucosa, the sub-mucosa, to the muscular layer, into which ultimately 
long, fibrous bands project. In the loose, submucous connective tissue 
the growth is most rapid, and here the nodules form in greatest num- 
bers. The so-called cancer-cells — groups of proliferating cylindrical 
epithelial cells — lie imbedded in a fibrous stroma, made up from the 
connective tissue of the mucous membrane. Within and about the 
stroma an infiltration of small cells appears, and out of or within these 
are formed numerous minute vessels. Thus, in a short time from the 
beginning of the process, all of the anatomical elements of the mucous 
membrane are appropriated by the new formation. In the course of 
development of scirrhus, the connective-tissue element, the fibrous 
stroma, takes on a preponderating growth over the epithelium cells 
and the small cell infiltration, with its newly formed vessels.* It is in 
consequence of this preponderance of the connective-tissue element, 
whether in distinct nodules or in a dense annular mass, that it presents 
such a cartilaginous appearance on section. A large part of the stom- 
ach may be converted into a mass of scirrhus, of one or two inches in 

* "V^^'aldeyer, Virchow's "Archiv.," vol. xli, p. 470, and vol. Iv, p. 67, "Die En- 
twickelung der Carcinome." Also Forster, "Lehrbuch der path. Anat.," pp. 110-115, by 
Siebert, Jena, 1873. Rindfleisch, " Text-Book of Pathological Histology," Lindsay & Blak- 
iston, 1872, p. 375, confirms Waldeyer's account of the origin of cancer in the mucosa. 
See also Rokitansky, and especially the great work of Cruveilhier, " Traite d' Ana- 
tomic Pathologique," where colloid will be found admirably delineated. 



54 



DISEASES OF THE DIGESTIVE SYSTEM. 



thickness, with nodules and protuberances of greater thickness pro- 
jecting into the cavity. A dense mass, of half to an inch in thick- 
ness, much less nodular, may surround the pylorus or the cardia, leav- 
ing a considerable part of the mucous membrane of the stomach free 
from disease, part of the mucosa exists after the cancer is devel- 
oped ; hence the internal surface of the stomach at that point is the 
surface of the cancer only, which is usually in an ulcerating state. 

Medullary cancer, or encephaloid, differs from scirrhus in the less 
growth of the fibrous stroma, and in a much more luxuriant prolifera- 
tion of the small cells and their associated vessels. Hence this form 
of the disease is softer, more vascular, and possessed of a greater 
power of rapid growth. Some parts of this form of cancer may, and 
usually do, retain the characteristic fibrous stroma of scirrhus. The 
internal or gastric surface usually consists of projecting nodules of 
softened cancer elements, which are easily detached and bleed readily. 
The ulceration which occurs in the exposed surface within the cavity 
of the stomach really consists in a process of fatty degeneration, the 
disintegration being produced by the solvent action of the gastric 
juice and the mechanical action of the food. 

Colloid cancer differs from the other varieties in that a gelatini- 
form degeneration of the cancer cells takes place, giving the j)eculiar 
colloid appearance. The distention of the alveoli by this material di- 
lates them so that they are larger than in other forms. This variety 
differs from the others also in that it is more widely diffused through 
the mucous membrane, and through neighboring organs, and is slower 
and longer in growth. It is also less common. 

Cancer, like ulcer, by setting up local peritonitis leads to the for- 
mation of adhesions, which affect the shape, position, and motions of 
the stomach. Adhesions may fix the pylorus in or about its true posi- 
tion, but, when unattached, the weight of the cancerous mass may 
drag it down, even as low as the hypochondrium, and thus constitute 
a movable tumor. When the annular deposits form at the pylorus, a 
stenosis of the orifice and dilatation of the cavity are results. When 
the same formation occurs at the cardia, the stomach very much con- 
tracts, and the a^sophagus immediately above dilates. In the vicinage 
of the connective-tissue bands, which stretch out through the subjacent 
elements, especially the muscular, considerable hypertrophy of these 
muscular elements at first results, but atrophy, from pressure of the 
newly formed connective tissue, finally occurs.* Those portions of 
the mucous membrane uninvaded by the cancer elements suffer chronic 
catarrh, in consequence, doubtless, of the continued hypera^mia. That 
from such a- state of the mucous membrane cancer may develop, is a 
popular notion, not supported by any scientific data. It is true that 



* Luton, " Cancer dc TEstomac," "Nouveau Diet, de Med.," Paris, 1871. 
6 



CARCINOMA OF THE STOMACH. 



55 



hypersemia of the cells of tlie cylindrical epithelium is apparently the 
starting-point of the development of cancer, but this hyperaemia is 
due to some peculiar irritation in the tissue. Cancer has developed 
from an old ulcer in some rare instances, but some remnant of gland- 
tissue must have remained. 

Cancer of the stomach is usually primary, and in most of the cases 
is confined to that organ. It is rare, indeed, for the stomach to be 
secondarily afPected ; but the author has seen a case in which cancer 
of the gall-bladder was followed by secondary deposits in the pylorus 
— an altogether unique case. In less than half the cases, cancer in- 
volves other organs as well as the stomach, and notably the liver, 
which is affected in about one fourth. Secondary deposits in the 
liver less often occur when the cardia is involved than when the lesser 
curvature and the pylorus are the sites of cancer. 

The principal complications of cancer of the stomach are fatty 
heart, thromboses, pneumonia, tuberculosis, etc. 

Symptoms. — In a few rare cases cancer has proceeded from its in- 
ception to its termination in the death of the patient without causing 
any distinctive symptoms. These are examples of cancerous infiltra- 
tion of the mucous membrane in the greater curvature, the orifices 
being unaffected. In the first stage, before a tumor can be detected 
or the cachexia is evident, the symptoms present are those of a dys- 
pepsia, which gradually assumes a more aggravated character. There 
is a good deal of pain from an early period, felt in the epigastrium 
usually, and increased by pressure, by food, and is also felt poste- 
riorly. The pain is nearly constant, and, although at times more 
severe, there are not, as a rule, those violent paroxysmal attacks so 
often found in ulcer. The pain is acute, often burning, sometimes 
lancinating, but by no means invariably so ; again, it is a sense of 
soreness and not severe pain ; rarely it is entirely absent, according 
to Brinton, in eight per cent.* 

The disorders of digestion increase with the duration of the case : 
the appetite declines ; distress after eating becomes greater ; then 
attacks of acidity and pyrosis, with regurgitation of an acrid, acid 
liquid, come on. Emaciation and loss of weight proceed at a uniform 
ratio. If annular deposits have been occurring at the cardia, the pa- 
tient early becomes conscious of a difiiculty in getting food into the 
stomach, but he almost invariably refers the obstruction to a point 
higher up. As the case advances, the alimentary substances pass 
slowly down to the cardia, where they are arrested for a minute or 
more, some portions trickling through into the stomach, the rest slowly 
returned by regurgitation, with a distinct gurgling noise. Consider- 

* " Medico-Cliirurgical Review," vol. xx, p. 4*79. Also Brinton on " Diseases of the 
Stomach." 



56 



DISEASES OF THE DIGESTIVE SYSTEM. 



able pain is experienced — a burning pain usually — when the substances 
swallowed reach the cardia, and as they pass through it into the 
cavity. This passage through the narrowed orifice is, as a rule, dis- 
tinctly recognized and accurately described. When the liquid or solid 
is disposed of, either by regurgitation or by entrance into the stom- 
ach, there is a feeling of relief, and the stomach digestion goes on with 
the ordinary facility. In cancer of the cardia, but a small portion of 
the mucous membrane is destroyed — the deposits being annular — and, 
as death takes place earlier by inanition than in any other form, there 
is not much interference with digestion, and these unfortunates suffer 
horribly from hunger. The epigastrium contracts and is drawn in 
toward the spine, owing partly to the exceeding general emaciation, 
and partly to the extreme contraction of the stomach. 

In the other forms of cancer, instead of arrest at the cardia, the 
patient feels no distress until the alimentary materials reach the stom- 
ach, when nausea and other distresses begin. Vomiting is one of the 
most constant symptoms, occurring in three fourths of the cases. At 
first the patient brings up in the morning, with a good deal of strain- 
ing, some tough, glairy mucus, and, it may be, a little bilious matter. 
Presently the vomiting comes on after eating ; if the cancer is situ- 
ated just below the cardiac orifice, and does not constrict it, pain, nau- 
sea, and vomiting, begin almost immediately after the food is swal- 
lowed. If the posterior wall is affected only, vomiting may not occur 
until late in the disease, and then may not be a very pronounced 
symptom. When the pylorus is affected, vomiting is a pretty nearly 
constant symptom, but it does not occur until some time after the 
food has reached the stomach — as a rule, not until two or three hours 
have elapsed. The vomited matters consist at first of the food in 
various stages of solution, then of mucus, containing sarcina and other 
minute organisms, and when the case is pretty well advanced there 
appear small brownish or brownish-black or chocolate-colored masses, 
of small size usually, which consist of decomposed blood. Vomiting 
ultimately occurs without the presence of food : it is then the form 
of vomiting entitled vomiting of irritation. Hiematemesis is a fre- 
quent but not a constant symptom, occurring in -somewhat less than 
half the cases (forty-two in one hundred, according to Brinton). If, 
however, the vomited matters were carefully searched for altered 
blood, it would probably be found present in nearly all cases. If the 
spectroscope were employed to examine all suspicious-looking parti- 
cles, the absorption-bands between C and D, characteristic of Inema- 
tin, would be often seen. Vomiting of blood in large quantity, as 
occurs in ulcer, is quite exceptional in cancer. Usually the blood is 
derived from small capillaries, but now and then sloughing takes place, 
and a vessel of considerable size is opened. The author has observed 
in some cases an enormous quantity of chocolate-colored, homoge- 



CARCINOMA OF THE STOMACH. 



67 



neous, granular material, discharged both by vomit and by stool, in 
cases of cancer at the pylorus. The condition of the bowel is that of 
torpor, but toward the end ichorous matter passing down the intestine 
excites diarrhoea. 

In one third of the cases observed by the author, salivation (not 
mercurial) was a symj^tom, and was either constantly or periodically 
present. The saliva had the ordinary appearance. The tongue is red 
at the tip and pointed, and is usually glazed. 

The cachexia induced by cancer is characteristic. TV^ith the prog- 
ress of emaciation, decline of strength is to be expected, but the sub- 
jects of the cancerous cachexia have an extraordinary sense of fatigue, 
which is felt when no exertion is made. The action of the heart is 
feeble, the pulse small, w^eak, and quick ; the respiration somewhat 
hurried. The least exertion increases the number of the heart-beats 
and the respiration movements. The skin is thin, dry, harsh, and in- 
elastic. The complexion is pallid, earthy, and bronzed, combined — a 
fawn color — and is strongly suggestive of the malady. Toward the 
end, oedema of the ankles appears— a mechanical result of the throm- 
boses. The cachexia, though it may be late, never fails to come on. 

A tumor is found in the proportion of eighty to one hundred cases. 
In some situations the tumors can not be felt, as when at the cardia, or 
in the lesser curvature, for here they are covered in by the left lobe of 
the liver. In other situations they may usually be detected by palpa- 
tion — suitable attention being given to all the sources of error. The 
variety of cancer does not necessarily affect the question of a tumor ; 
but a colloid growth may be diffused through the walls of the stomach, 
giving to the sense of touch the impression of thickening, and not of a 
defined tumor. On palpation, the tumor, if it exist, is felt to be hard, 
somewhat irregular, and nodular, if scirrhus, but softer and more elas- 
tic, yet well defined, if encephaloid or colloid. Even when in a position 
to be felt, it may elude search by reason of distention of the stomach, 
or of adhesions which may change the shape and position of the organ, 
or the presence of fluid in the peritoneal cavity — a result of the pressure 
of secondary deposits in the liver. Tumor of the liver, of the pancreas, 
movable kidney, aneurism, may be confounded with tumor of the stom- 
ach, and must be kept in view when making a diagnosis by exclusion. 
The relation of the tumor to the movements of the diaphragm should 
be noted ; for a tumor of the stomach does not descend when the lung 
is inflated with air. When the pylorus remains free the weight of the 
neoplasm causes it to fall down, sometimes as low as the hypochon- 
drium, and it continues movable. Tumors of the liver and spleen descend 
on full inspiration, but the pyloric tumor when adherent retains its posi- 
tion, and when movable is not influenced by the respiratory movements. 
When a scirrhus lies upon the aorta, a pulsation is communicated to it, 
but it is not an expansile pulsation, and there are none of the other 
signs of aneurism, yet mistakes of diagnosis are not infrequent. 



68 



DISEASES OF THE DIGESTIVE SYSTEM. 



Like ulcer, cancer may result in perforation and general peritonitis ; 
in the formation of fistulous communications with the walls of the 
abdomen, externally ; with the transverse colon, when there will be 
stercoraceous vomiting ; with the thoracic cavity ; but these are com- 
paratively rare complications. Occasionally a large vessel is laid open, 
and death ensues from sudden and large hjemorrhage. In accordance 
with its nature, cancer tends to spread to contiguous parts by reason 
of immediate vascular communication. The cancer elements are much 
more frequently deposited in the liver than in any other organ. Asci- 
tes, icterus, thrombosis of the portal vein, etc., are the most important 
results of the implication of the liver. Extension of the disease also 
occurs by the lymphatics, and large nodular masses of degenerating 
mesenteric glands may be felt through the thin parietes of the abdo- 
men during the life of the patient. The cervical lymphatics, just above 
the clavicle, also sometimes enlarge and aiford valuable indications of 
the nature of the malady, even early in the course of the disease. 

Tuberculosis of the lungs is a frequent complication of cancer of 
the stomach. 

Course and Duration. — Cancer of the stomach is an essentially 
chronic disease. The average duration, according to Brinton, is one 
year ; but the cases differ in duration according to the anatomical site. 
Named in the order of their fatality they stand as follows : cancer of 
the cardia, of the pylorus, of the lesser curvature, of the greater curva- 
ture. The maximum duration is three years. 

Diagnosis. — The differentiation is to be made between chronic gas- 
tric catarrh, chronic ulcer, and carcinoma. In the early stages of ulcer 
and cancer it may be impossible to separate them from chronic gastric 
catarrh ; but as these cases progress the points of difference become 
distinct. The following considerations will enable a correct differentia- 
tion to be arrived at : chronic gastritis may occur at any age ; there 
is rarely any severe pain, and it is diffused over the whole organ ; 
vomiting is only occasional, and then of alimentary matters, as a rule ; 
there is no important variation in the body-weight, and no progressive 
emaciation. In ulcer the pain is severe, localized to a small point in 
front and behind ; there is much vomiting and hsematemesis, the blood 
coming up in considerable quantity, little or not at all altered. The 
subject of cancer is well advanced in life (from forty to sixty) ; the 
pain has a lancinating character, and is felt in one place, which is the 
same for each case, but differs in different cases ; there is vomiting, es- 
pecially vomiting of chocolate or coffee-ground masses of decomposed 
blood ; above all, the presence of a tumor. The presence of an excess 
of indican in the urine has been held to be diagnostic, but, as Jaffe* 
has shown — and this observation has been confirmed by Hoppe-Seyler 
— the quantity of this substance is much increased in carcinoma of the 
liver, in obstruction of the intestines, and other diseases. 

* " Centralblatt f. d. med. Wissenschaften," p. 2, 1872. 



CARCINOMA OF THE STOMACH. 



59 



Treatment. — Although cancer of the stomach is incurable, much 
may be done by treatment to render the patient's decline tolerable. 
The first and most important point is to regulate the diet. By the 
withdrawal of solid food, and the substitution of milk alone, or milk 
and beef-juice, the greatest relief is afforded, and for a time there may 
be a gain in weight, but of course this is not long maintained. If the 
diet is restricted to the articles mentioned, it should be supplemented 
by that important means of rectal alimentation, the injection of defibri- 
nated blood. The burning pain is much diminished by washing out 
the stomach once a day with the stomach-pump, especially in dilatation 
from stenosis of the pylorus. By removing acrid and acid matters in 
this way, much straining efforts at vomiting will be saved. 

Of all the remedial measures proposed there is no prescription 
which is so generally useful in these cases as equal parts of pure car- 
bolic acid and tincture of iodine, of which one or two drops may be 
administered in water three times a day. For the vomiting only, a 
solution in cherry-laurel water of carbolic acid, or a combination of 
carbolic acid with bismuth in an emulsion, will be found effective. 
Nitro-glycerin, benzine, and bisulphide of carbon have been used, with 
advantage, to allay nausea and vomiting. The most effective means to 
relieve pain is the hypodermatic injection of morphine. The stomachal 
administration of the same agent is inefficient, owing to the diminished 
absorption power of the organ. Laudanum by enema, morphine in the 
form of suppository, or the endermic use of morphine, are preferable to 
the stomach administration. Great care is necessary in the prescription 
of anodynes, for the need grows rapidly, and the consumption becomes 
enormous, reducing the patient to a mental and moral weakness dread- 
ful to contemplate. 

Arsenic, in the form of Fowler's solution, one or two drops, three 
times a day, has considerable power to allay pain, and is not without 
influence in retarding the growth of epithelial cancer. As respects the 
power to relieve pain, the physiological basis for its employment is the 
action of arsenic, in toxic doses, on the nervous system of animal life. 
It has been repeatedly observed that sometimes, in large doses, no 
vomiting was produced, but coma and insensibility followed. A great 
many facts have now been accumulated, proving that cancer of epithe- 
lial origin may be greatly retarded in its growth by the persistent use 
of moderate doses-— two drops of Fowler's solution ter in die. 

The author's considerable experience in the treatment of carcinoma 
of the stomach warrants the statement that the best results are obtained 
by the persistent use of carbolic acid and iodine, in the form advised 
above, and of arsenic, in the form of Fowler's solution. It may not 
be needless to observe that these agents should not be given in one 
prescription — the carbolic acid and iodine together, the Fowler's solu- 
tion at another time. 



60 



DISEASES OF THE DIGESTIVE SYSTEM. 



aSIMATEMESIS— HEMORRHAGE OF THE STOMACH— VOMIT- 
ING OF BLOOD. 

Definition. — Hgematemesis and vomiting of blood do not adequate- 
ly name the malady, for blood may be swallowed and then vomited. 
Haemorrhage of the stomach is the correct term. 

Causes. — Rupture of a stomach blood-vessel is the essential condi- 
tion of stomachal haemorrhage, notwithstanding, under some circum- 
stances, diapedesis of the corpuscular elements does occur. Sufficient 
blood must escape to excite nausea and vomiting. During an inflam- 
matory stasis, considerable blood may escape from ruptured capillaries, 
but usually haemorrhage is due to the giving way of vessels of some 
size ; diapedesis, certainly, is quite inadequate to bring about the es- 
cape of much blood. There may be disease of the tunics of the blood- 
vessels sufficient to cause them to give way on slight increase of the 
blood-pressure. Furthermore, long-continued abnormal pressure will 
induce slow changes, without invoking other causes to account for 
their yielding should the pressure suddenly become greater. In this 
way may we explain the occurrence of gastric haemorrhage in cirrho- 
sis, acute yellow atrophy of the liver, yellow fever. Certain lesions, 
acting mechanically on the portal vein, bring about the same results — 
for example, an aneurism of the hepatic artery, a large calculus, or 
tumors in the neighborhood of the portal vein. Any obstruction of 
the portal vein may be the cause of blocking by a thrombus of a ves- 
sel returning blood from a certain part of the mucous membrane — the 
effect of this being the production of one or a number of superficial 
ulcers. Severe and protracted haemorrhage may proceed from such 
erosions. Still more remotely is the occurrence of gastric haemorrhage, 
caused by increased pressure in the portal system due to obstructive 
troubles of the lungs and heart. The haemorrhagic diathesis may 
manifest itself in haemorrhage from the gastric mucous membrane. 
Arrest of an haemorrhoidal discharge, which has continued for a long 
time, is supposed, by a sudden increase in the blood-pressure within 
the portal system, to be a cause of haemorrhage of the stomach. 

According to the statistics of Handfield Jones, in seventy-two 
cases of haematemesis there were fifty-three females to nineteen males 
— showing a great preponderance in the female sex. As regards age, 
from twenty to forty there were nine males and thirty-six females, 
and after forty, eight males and fourteen females. These facts indi- 
cate that vicarious menstruation through the stomach must be rela- 
tively frequent. As in forty the existence of ulcers seemed probable, 
it is rendered pretty certain, by these figures, that ulcer is the most 
common cause of stomach haemorrhaofc* 



* ** Medico-Chirurgical Transactions," vol. xliii, p. 353. 



YOMITIXG OF BLOOD. 



61 



Pathological Anatomy. — More or less coagulated blood, acted on 
by the acids of the gastric juice to a varying extent, is found in the 
stomach. It is often impossible to discover the source of the haemor- 
rhage, unless the hsemorrhagic erosions, abeady alhided to, have 
formed. They are usually situated in the neighborhood of the pylo- 
rus. "When a large vessel has given way, the rent can usually be 
found Tvith a coagulum in it. 

Symptoms. — When a haemorrhage occiu's sufficient in amount to 
produce definite symptoms, the patient experiences a sensation of 
warmth in the stomach, while the periphery is cool or cold ; distention, 
nausea, faintness. If the haemorrhage is large, coming suddenly from 
a vessel of considerable size, without any apparent cause, the patient 
turns sick, faint, pallid, and cold, the stomach is distended, and then 
vomiting sets in, the blood rushing up in a full stream through the 
mouth and nose, or if less in amount it comes up by successive acts of 
vomiting. The faintness usually increases at the sight of blood, and 
only passes off on the cessation of the bleeding. In rare instances a 
large haemorrhage occurs, the stomach is fully distended and returns a 
perfectly flat percussion-note, the patient becomes pale and cold and 
faint, or he actually does faint and is convulsed, without any vomit- 
ing, the blood subsequently passing ofi^ by stool. A patient enfeebled 
by disease may be suddenly carried off by a haemorrhage in the stom- 
ach without vomiting. It not unfrequently happens that, when the 
blood comes up with a sudden gush, some is carried into the larynx, 
where it excites coughing, and hence may appear to be coughed up. 
This fact leads to erroneous interpretation of the nature of the case, 
and confusion as to the source of the haemorrhage. The appearance 
of the blood is different according to the time it has been acted on by 
the gastric juice. If it comes up at once in large quantities, it is part- 
ly fluid and partly coagulated, like ordinary blood ; but, if it has been 
retained, it has a blackish, or brownish-black, or chocolate appearance, 
and is then rather granular in structure. If but little blood has es- 
caped and slowly, it presents the " coffee-ground " appearance. The 
gastric juice decomposes the haemoglobin and sets free the haematin, 
which gives the color to the vomited matters. In concealed haemor- 
rhage of the stomach, the blood passing into the intestines, and in in- 
testinal haemorrhage, the same phenomena ensue : there occur sudden 
distention of the abdomen and colic-like pains, faintness or actual 
fainting with its attendant symptoms, if the loss of blood be large, 
and the stools of tarry-like material, altered blood, at first mixed with 
ordinary faeces, and then consisting of the decomposed blood only. As 
narrated in the previous article, the author has observed chocolate- 
colored material in large amount discharged by stool. It assumes 
this appearance when acted on by alkaline fluids, after the effect of 
acids. If this be correct, we have a means of determining whether 



62 



DISEASES OF THE DIGESTIVE SYSTEM. 



any given discharge of blood originated in the stomach or intestine. 
Blood so colored may be vomited, but it comes up after the stomach 
is emptied, and is forced by the act of vomiting from the duodenum. 
A very singular result of stomach haemorrhage is amaurosis, first ob- 
served by Graefe, then Fikentscher, and afterward by Hutchinson. 
No explanation that has been offered satisfactorily explains the oc- 
currence of double, incurable amaurosis after haemorrhage from the 
stomach. 

Course, Duration, and Termination. — Occasionally vomiting of blood 
is fatal, as when an aneurism ruptures into the stomach. Although 
the patient may be faint, cold, and convulsed, yet haemorrhage of the 
stomach is rarely fatal, and the patient slowly emerges from the con- 
dition of anaemia. The pain of ulcer and cancer is often much re- 
lieved by vomiting blood ; but the case of ulcer may be made much 
more serious by it in all other respects. Haemorrhage due to cirrhosis 
of the liver far advanced may be difiicult or impossible to control, 
and may add materially to the dangers of the case, or may cause 
death by exhaustion. 

Diagnosis. — The juices of colored fruits (of black raspberries, for 
example) may be mistaken for blood, especially when vomited in the 
night. The author has encountered several cases of this kind. The 
microscope or the spectroscope may be invoked to decide. Much 
greater difficulty must exist in determining the source of the blood, 
whether swallowed and vomited, or derived from the stomach or lungs. 
An examination of the nares will usually demonstrate the origin of the 
bleeding, if the blood proceeds from any part of the nasal mucous 
membrane. 

Blood from the lungs has an alkaline reaction, is aerated, a bright 
red, and may contain mucus or pus. Blood from the stomach is acid 
in reaction ; when acted on by the gastric juice, is blackish, brownish- 
black, or chocolate color, and is not aerated, and may be mixed with 
food. The act of vomiting brings up the blood from the stomach, of 
coughing from the lungs (coughing may attend vomiting of blood, and 
vomiting — the patient swallowing blood coming from the lungs — may 
attend pulmonary haemorrhage). The previous history of pulmonary 
disease and the existence of moist rales at the time of the haemorrhage 
indicate the lungs to be the seat of the haemorrhage, and the absence 
of all the physical evidences of fullness of the stomach negatives the 
idea of stomachal haemorrhage. The attack begins in the lungs, by a 
sense of heat under the sternum, by a soreness in some locality, and 
by a sense of constriction of the chest ; in the stomach, by a sense of 
fullness and actual distention of the stomach, followed by nausea. 
After the attack of pulmonary haemorrhage the patient experiences 
soreness at the seat of the haemorrhage ; there is more or less elevation 
of temperature, often a pneumonia or bronchitis of small extent ; moist 



VOMITING OF BLOOD. 



63 



rdleSy and the expectoration for several days of small, "brownish-bloody 
sputa. After the hsematemesis, only the depression and anaemia are 
present except stools of altered blood, which are usual. 

Treatmeiit. — The haemorrhage, which is a vicarious menstruation, 
is relieved by diverting the flux to the uterus, its natural outlet. This 
is best accomplished by the use of the appropriate emmenagogues dur- 
ing the interval, of hot sitz-baths and hot vaginal douches, at the time 
of the expected flow. In the case of married women, leeches may be 
applied to the cervix uteri at the time of the menstrual molimen. 
When due to arrested hsemorrhoidal discharge, leeches should be ap- 
plied to the anus, and aloes be administered. 

When an impoverished condition of the blood exists, or when the 
so-called hsemorrhagic diathesis is the cause of haemorrhage, effort 
must be directed to improve the composition of the blood, and to ele- 
vate the tonus of the vessels. When the haemorrhage is occurring, the 
most absolute repose must be enjoined ; the patient should swallow as 
rapidly as possible pellets of ice ; ergotin should be injected subcuta- 
neously, as much as three to six grains at a time, and it may be repeated 
as often as necessary ; a bag of ice should be put on the epigastrium ; 
and large draughts of iced alum- whey should be swallowed every few 
minutes. Ligatures around the thighs, tied tightly enough merely to 
stop a part of the venous blood in the lower limbs, is an excellent 
adjunct to the measures above proposed. If this is not done, the legs 
should hang down out of the bed, and the shoulders should be some- 
what raised. The salts of iron (chloride, nitrate, subsulphate) may be 
administered for their styptic effect. A teaspoonful of the tincture 
of the chloride can be given in four ounces of ice-water. An objection 
to these ferruginous styptics is the very voluminous and nauseating 
coagula which they form, and which are apt to excite vomiting. Bran- 
dy is an excellent local astringent, and is generally serviceable in these 
cases, owing to the syncope. The stimulant is beneficial in raising the 
arterial tension, by furnishing a force for the vaso-motor system, which 
is in a state of paralysis. Tannic acid is a safe styptic, which can be 
used frequently and in relatively large (ten grains) quantity. Sulphuric 
acid may be employed successfully, and this has the advantage that a 
small quantity imparts astringent property to a large amount of water. 
Next to alum-whey it is the most eflicient haemostatic. If vomiting is 
obstinate, the one sixteenth grain of morphia hypodermatically will 
stop it, and contribute materially to the arrest of the haemorrhage. 

If the haemorrhage has been suflicient to cause dangerous syncope, 
inhalation of nitrite of amyl may arouse the failing heart, or the injec- 
tion of digitaline may be tried. Leube advises the subcutaneous in- 
jection of ether — a syringeful every few minutes — in cases of danger- 
ous syncope from the haemorrhage. Yery great care is subsequently 
required in the alimentation, and in the use of remedies to remove the 



64: DISEASES OF THE DIGESTIVE SYSTEM. 

an£eniia. Only milk should be permitted for some days ; but this may 
be supplemented most advantageously by the rectal injection of defi- 
brinated blood. 

DILATATION OF THE STOMACH. 

Causes. — Dilatation of the stomach is most frequently produced by 
stenosis of the pylorus. The great cause of narrowing of the pyloric 
orifice is cancer, but it may be due to chronic inflammation, hyperpla- 
sia, and subsequent contraction of the submucous connective tissue, or 
to hypertrophy and contraction of the muscular elements — the so-called 
sphincter — of the pylorus. These forms of local disease, limited to 
this locality, are excessively rare, while cancer is common. Exterior 
pressure, as of cancer of the pancreas, a floating kidney or other tumor, 
may cause stenosis of the pylorus and subsequent dilatation of the 
stomach. Dilatation of the stomach may be the result of excessive 
indulgence in the use of fluids, notably of beer. The author has ob- 
served several cases, in beer-drinkers, who drank ten, twenty, even 
forty, glasses of beer habitually every day. 

Pathological Anatomy. — When stenosis exists at the pylorus, the 
whole organ is dilated, often enormously so, but the enlargement is 
not universal and uniform from the beginning ; the dilatation com- 
mences in the fundus. With the development of the stenosis there 
ensues hypertrophy of the muscular layer, in accordance with the well- 
known pathological law. In dilatation without stenosis of the pylorus 
the muscular layer is thinner than normal, pale in color, and more or 
less advanced in fatty degeneration ; the mucous membrane is, also, 
thin, pale, and without rugae. Stenosis of the pylorus is caused chiefly 
by cancer, and hence the lesions peculiar to this new formation will be 
present. If ulcers have been excavated at the margin of the orifice, 
have subsequently coalesced, and cicatrized, the results of the contrac- 
tion of the cicatricial tissue will be seen in a distorted and contracted 
pylorus. 

Symptoms. — When stenosis of the pylorus and dilatation of the 
stomach are results of cancer formation, the symptoms of dilatation 
are quite dominated by those of cancer. It is necessary, here, to dis- 
cuss the former only. The symptoms are those of chronic gastric ca- 
tarrh, or of dyspepsia. There are three signs in addition to those of 
dyspepsia, which indicate dilatation of the stomach : rather persistent 
vomiting ; return of food partly chymified and partly undergoing 
fermentative and putrefactive changes ; the physical evidence of en- 
largement. The cavity having greatly increased capacity, enormous 
accumulations may take place, and hence when vomiting occurs the 
amount discharged will be great. The attacks of vomiting are more 
frequent than is usual in ordinary cases of dyspepsia, and they may 
become habitual. Regurgitation is a common symptom — particles of 



DILATATION OF THE STOMACH. 



65 



partly digested aliment, acid, acrid, and offensive, and foul gases, com- 
pounds of hydrogen with sulphur and phosphorus, coming up. In 
these acid and pasty materials is found the parasite Sarcina ventri- 
cmU, It is not yet known whether this minute organism is a cause or 
a consequence of the conditions present ; but it is so often associated 
with dilatation of the stomach as to have some diagnostic value. The 
bowels are torpid, the faeces dry. The nutrition is much impaired in 
consequence of the insufficient conversion of the food, and the dimin- 
ished absorption. Hence the patients affected with this malady waste, 
and, as the blood is deficient in water, they suffer from muscular cramp, 
chiefly of the flexors. These cramps were first described by Kussmaul 
(Leube), but the author has repeatedly observed them in cancer of the 
stomach, in diabetes, etc., and everybody knows that they occur in 
Asiatic cholera, the same cause, dehydration of the blood, operating in 
all these maladies to produce them. 

The physical signs of dilated stomach are as follows : On inspec- 
tion, an abnormal fullness and prominence of the whole stomach region 
will be seen ; on percussion, the signs vary according to the state of 
the organ ; if empty, a tympanitic percussion-note, of a somewhat 
metallic quality and extending from the sixth intercostal space to or 
below the umbilicus, is developed ; if full, it is high pitched and flat, 
and, on assuming the upright posture, there is a zone of dullness at the 
lower part of the space which in the recumbent posture returned a tym- 
panitic note. On auscultation of the dilated stomach, there is almost 
always heard a good deal of succussion — splashing of the fluid in the 
cavity — when the body is suddenly and strongly shaken. Placing the 
stethoscope over the pylorus, and smartly compressing the left hypo- 
chondriac and lumbar regions, the splashing of the contents of the 
stomach can be readily heard. The dimensions of the stomach when 
distended may be demonstrated by causing an abundant evolution of 
carbonic-acid gas from the reaction of sodium bicarbonate and tartaric 
acid — a solution of the former being given and followed by a solution 
of the latter. Another means of diagnosis consists in passing the 
stomach-tube, and noting the point at which it may be felt through the 
abdominal parietes. 

Treatment. — The first and most important duty is a careful adapta- 
tion of the diet to the conditions present. The form of alimentation suit- 
able to these cases is " dry diet," * a diet without fluids. The quantity 
of other foods should be small, and as far as possible " water-free." 

As paresis of the muscular layer of the stomach is an important 
factor in the dilatation, means must be employed to correct this. 
Strychnine hypodermatically, in the epigastrium, is an excellent expedi- 

* See my treatise on "Materia Mcdica and Therapeutics," article "Alimentation in 
Disease." ^ 



66 



DISEASES OF THE DIGESTIVE SYSTEM. 



ent. Tincture of nux vomica and tincture of physostigma are effective 
remedies — ten to twenty drops of each — three times a day before 
meals. Great benefit is obtained from the use of galvanism, one elec- 
trode placed just beneath the mastoid process and the other at the 
epigastrium, and a mild current (from five to twenty cells of Siemens 
and Halske), slowly interrupted, passed through the pneumogastric. 
Fermentation should be prevented by the use of the sulphites, carbolic 
acid, etc., but especially by abstaining from starchy and saccharine 
substances, which produce a great quantity of carbonic-acid gas. The 
decomposing foods, the fat acids set free by the fermenting butter and 
other fats, and the unhealthy mucus which is poured out in great quan- 
tity, keep up irritation which renders futile the use of the ordinary 
remedies. This fermentative and decomposing mass must be removed 
from the stomach. The expedient first advocated and employed by 
Kussmaul — washing out the stomach with the pump or siphon — has 
proved to be useful, but it does not maintain the same position, as a 
therapeutical means, as on its first introduction. Recently Kuster * has 
opposed its use on several grounds, and advised the treatment by muri- 
atic acid, Carlsbad salts, and nitrate of silver. , If the stomach-pump or 
siphon be used, the stomach should be thoroughly washed out every 
day. The author can not doubt that, if an emetic is first given, and is 
followed by an active saline cathartic, the stomach will be thoroughly 
emptied, and as efiiciently as if the stomach-pump were employed. 
Then,- if distention be avoided, a suitable diet enjoined, and remedies 
to promote contraction of the muscular layer prescribed, the best results 
can be obtained of which our present resources will admit. 



DISEASES OF THE INTESTINES. 



CATARRH OF THE INTESTINES. 

Definition. — Catarrh of the intestinal mucous membrane may exist 
in the acute or chronic form. It receives different designations as it 
affects the various divisions of the intestinal tract. Catarrh of the 
duodenum is duodenitis ; of the ileum, ileitis / of the colon, colitis ; 
and of the ileum and colon together, ileO'Colitis. When it is limited 
to the C£ecum it is called typhlitis^ and when to the rectum, proctitis. 
Again, the designation is derived from some special characteristics, as 
cholera morbus, cholera infantura, etc. 

* "Allgemeine med. Central-Zeitung," 1876, Xo. 98. 



INTESTINAL CATARRH. 



67 



To avoid repetition, those points in the morbid anatomy in which 
these several forms agree may be first described with advantage. 

Pathological Anatomy of Catarrh of the Intestines.— In the ca- 
tarrhal process, there ensues first hyperaemia of the mucous membrane, 
which is manifested by redness, swelling, and oedema ; next, nutritive 
alterations, which consist of granulation of the protoplasm, over- 
growth and desquamation of the epithelium. The injection occurs 
most decidedly about the glands, but it may be uniformly diffused, 
the whole surface affected, or the redness may be in patches and re- 
stricted to particular localities. One result of active hyperaemia is 
rupture of capillaries and extravasation of blood ; another is increased 
secretion and exudation, consisting of the products of glands, abnor- 
mally active, desquamating epithelium, proliferating cells, and migrat- 
ing white corpuscles. In these changes consists the morbid anatomy 
of an acute catarrh of a mucous membrane. 

In chronic catarrh, which succeeds to the acute form, generally, 
the changes are similar, but possess also special character. Long-con- 
tinued hypersemia induces changes in the vessels — over-distended they 
remain enlarged, the veins tortuous and varicose ; remains of old ex- 
travasations of blood are seen in a brownish, slate-colored pigment 
deposit, most abundant in the villi. The mucous membrane contin- 
ues swollen and oedematous ; the cells of the epithelial layer are altered 
in respect to their nuclei and protoplasm, which have become cloudy 
and are more or less advanced in fatty degeneration. The glands and 
agminated follicles become prominent from an excessive formation 
and accumulation of their contents ; as a result of the pressure of 
proliferating cells, necrosis occurs, and sloughs separate, leaving ul- 
cers ; or the glands remain prominent and brownish and slate-colored 
from changes in previous extravasations. The mucous membrane is 
covered with a tenacious mucus rich in pus-cells, which strongly ad- 
heres, or with a more abundant and less tenacious purulent exudation. 
Owing to an accumulation of their contents, the agminated patches 
with solitary follicles are enlarged, their orifices appearing as minute 
black points, the whole forming a very characteristic appearance. 

In chronic catarrh the anatomical alterations are not limited to the 
mucous membrane and its glandular appendages. The hypersemia ex- 
tends to the mucosa ; its vessels, especially the veins, enlarge, and the 
connective tissue, in some situations, undergoes hyperplasia and thick- 
ens, forming prominences. Instead of hypertrophy, an atrophic change 
may result from chronic catarrh, but a very great duration of the dis- 
ease and the immaturity of early life are necessary. 

The muscular layer of the intestine, if a catarrh has long per- 
sisted, may undergo hypertrophy, and, in rare cases, to such an ex- 
tent as to encroach on the cavity and greatly lessen the capacity of 
the bowel. 



68 



DISEASES OF THE DIGESTIVE SYSTEM. 



CHOLERA MORBUS. 

Definition. — An acute catarrh of the stomach and intestines, of sud- 
den onset, and manifested objectively by vomiting and purging. It 
is also called cholera nostras, sporadic cholera, etc. 

Causes. — Climatic influences are the most important. It is a dis- 
ease more especially of summer and early autumn, although it may 
occur under certain circumstances at any season. Tartar emetic, ela- 
terium, and other irritants will bring on vomiting and purging not to 
be distinguished from a severe cholera morbus. Irritants of all kinds, 
unripe fruits and vegetables, fermentation of foods in the stomach, 
will excite an attack. 

Pathological Anatomy. — Death may ensue without there being any 
defined alterations of structure. In ordinary cases there are present 
the changes of acute gastro-intestinal catarrh ; the mucous membrane 
hyperjemic ; the epithelium desquamating ; the glands swollen and 
prominent ; the blood thick and of a prune-juice color ; the serous 
membranes everywhere dry, sticky, and coated with desquamated 
epithelium ; the kidneys hyperjemic, the epithelium of the tubules 
also being cast off ; the muscles of the body becoming granular, etc. 
— the morbid anatomy, indeed, of true cholera, except in degree. 

Symptoms. — An attack of cholera morbus may be preceded by 
some diarrhoea, nausea, a coated tongue, and general malaise for a day 
or two, but usually it sets in suddenly and with violence. In the 
night, as a rule, and usually after midnight, the patient is awakened 
by a chill or a sense of chilliness, some intestinal pain (colic) and nau- 
sea, and vomiting then begins ; or, without any premonition, the pa- 
tient awakes with intense nausea, and then vomits immediately. The 
vomited matters at first consist of the ordinary contents of the stom- 
ach. Simultaneously, purging begins, the first evacuation containing 
more or less of ordinary faeces. Presently the matters discharged by 
vomit and stool are liquid, whitish, or of a green or yellowish tint, 
consisting of mucus and sero-mucus. In the severe cases, approxi- 
mating to the true cholera type, the matters vomited or passed by 
stool are copious, thin, whitish, odorless, or having a faint mouse-like 
odor, and consist of blood-serum with mucus and cast-off epithelium 
(rice-water discharges). The discharges occur in quick succession, 
and so enormous is the loss of material that in an hour or two the pa- 
tient may be so much reduced as to be unable to rise from the bed ; the 
body shrinks, the face becomes pinched and cyanosed, the surface cold 
and covered with a clammy sweat ; the hands shrivel and have a sod- 
den appearance ; the voice is husky, the tongue is cold, the breath is 
cold. The patient is tormented with an intolerable thirst, but the drink 
is rejected as soon as swallowed. The urinary secretion rapidly di- 
minishes in amount, and in the worst cases is suppressed. The urine 



CHOLERA MORBUS. 



69 



contains traces of albumen, casts of the tubules — the desquamated 
epithelium — and is deficient in the amount of urea and salts. The 
effect of this enormous waste from the intestinal canal is to diminish 
the water of the blood, and hence to relax the circulation. The action 
of the heart becomes so feeble that the pulse may not be felt at the 
wrist. Another result of the dehydration of the tissues is the occur- 
rence of cramps, especially in the muscles of the calf, and they cause 
severe suffering, the patient crying out w^hen they come on. They 
may occur in the muscles of the upper extremity, and also in the mus- 
cles of the neck. In some cases, enormous accumulation of the rice- 
water material may take place because of a paralytic state of the 
bowel, and no discharge occur by vomit or stool, yet the patient passes 
quickly into collapse. 

From the simplest case of cholera morbus, which ends spontane- 
ously when the stomach and intestines are emptied, up to the severe 
algid form, there are numerous intermediate examples of every degree 
of severity. 

Course, Duration, and Termination— The subsequent clinical his- 
tory of the cases depends much on the severity of the attack. The 
mild case terminates without treatment, and the next day, although 
somewhat weak, the patient is about as usual. In the severer cases, 
after several hours the number of the evacuations lessens, and their 
character is changed, the skin becomes warm, the pulse rises, and the 
normal is presently restored, but the mucous membrane remains sensi- 
tive, and care in alimentation is necessary for several days. In the 
severest cases — those of the cholera type — recovery from the algid 
stage is gradual, reaction comes on slowly, but passes the norm into 
a fever, of type remittent and of character typhoid, which may con- 
tinue a week or more. In the fatal cases, the mode of dying is by col- 
lapse, or in the secondary fever by exhaustion. 

The cases are very uniform, but differ much in severity. The du- 
ration is from a few hours to two or more days, and, in the rare 
cases of secondary fever, to two weeks. The termination is in a great 
majority of cases in health, the mortality being about three per cent, 
of uncomplicated cases. An attack of cholera morbus may be the 
mere prelude to an acute diarrhoea or dysentery, more frequently the 
latter. An attack of cholera morbus may be the mode of dying from 
chronic interstitial nephritis. 

Diagnosis. — The phenomena attendant on cholera morbus are so 
characteristic that a mistake of diagnosis would seem to be difficult. 
During the existence of a cholera epidemic, the severer cases of chol- 
era morbus may be mistaken for cholera, but, as they do not differ in 
any respect, not even in morbid anatomy, there need be no attempt at 
differentiation. Cholera morbus, a substantive affection, may be con- 
founded with choleriform attacks due to urtemia. The distinction is 



TO 



DISEASES OF THE DIGESTIVE SYSTEM. 



to be made by reference to the previous history, the presence of 
albumen and casts in the urine, and the cerebral symptoms, which, in 
some form, occur in uraemia. 

Treatment. — In simple cholera morbus due to the ingestion of some 
irritating or indigestible food, or to fermenting materials, no treat- 
ment may be necessary. When the cause is removed the morbid 
action ceases. In the more severe cases prompt action is necessary, 
especially when cholera is prevalent. No remedy compares in effi- 
ciency to the hypodermatic injection of morphine and atropine — J to 
of a grain of the former and yl-g- of a grain of the latter.* Those 
entirely unaccustomed to the action of opium — women, and men of the 
nervous and impressionable type — should receive the smaller dose. In 
many cases, a single injection suffices to terminate the attack. The 
repetition of the injection will depend on the severity and persistence 
of the seizure, and on the susceptibility of the patient. It is usually 
better not to repeat the injection within the hour. The eifect which 
it has is most striking : the vomiting and purging cease, the pulse 
rises, the surface becomes warm, and the cramps are no longer felt. It 
is rare, indeed, if these results are not obtained promptly, rendering 
unnecessary any subsequent treatment except some correcting medi- 
cine. In the cases of the cholera type, the patient passing into the 
algid stage, additional means may be necessary. The use of chloral 
hypodermatically with morphine is then remarkably beneficial. The 
author has observed that under these circumstances chloral will re- 
lieve the cramps and bring about reaction, when morphine, alone or 
with atropine, had seemed inadequate. 

Other means of treatment may be employed in conjunction with 
the hypodermatic injections, or without them. Sinapisms of large size 
should be applied to the abdomen, but not allowed to remain longer 
than sufficient to produce a sensation of burning, or the appearance of 
redness. Pellets of ice may be repeatedly swallowed. Iced cham- 
pagne, very dry, will sometimes be retained when other things are 
rejected. Carbonic-acid water and effervescing soda-powders are very 
grateful and also serviceable. The medicines most easily borne and 
most efficient are combinations of the mineral acids and opium, of 
which, the well-known Hope's mixture is a type. Diluted sulphuric 
or muriatic acids with the tincture of opium in camphor-water, are 
the best of these combinations. The mistake is frequently, indeed, 
usually made, of giving the mineral acids in too large doses, and 
hence they are immediately rejected. From two to five drops of di- 
luted sulphuric, or the same dose of diluted muriatic acid, and the 
same quantity of tincture of opium, should be given from every half 
hour to every two hours, in a sufficient quantity of ice-water. An 

* "Manual of Hypodermic Medication," fourth edition. Philadelphia: J. B. Lippin- 
cott & Co., 1882. 



CHOLERA INFANTUM. 



71 



acid solution is much more grateful, and also more easily borne, than 
any other kind of medicine. Carbolic acid alone, or in a mixture with 
bismuth, is an efficient means for arresting vomiting. Besides its 
properties as an antiferment, it has a local anaesthetic action on the 
terminal filaments of the nerves in the mucous membrane. The ef- 
fects of carbolic acid, creosote, and other agents of the same kind, are 
exerted on the stomach chiefly, and hence are less useful in affections 
of the intestines. Iodine tincture, and carbolic acid, in equal parts — 
a half grain of each — every half hour, is an effective combination, of 
great utility in irritable stomach. When remedies of the kind just 
now mentioned are given by the stomach, they should be supple- 
mented by enemata of starch and laudanum, repeated according to 
circumstances. 

Very small doses of calomel — one twelfth to one sixth of a grain — 
have remarkable sedative effect on the gastro-intestinal mucous mem- 
brane, relieving vomiting and suspending the purging. It is often 
given with opium, with rhubarb, piperine, etc., but such combinations, 
except that with opium, are of doubtful utility. Aromatic and astrin- 
gent remedies are much used in various combinations to arrest vomit- 
ing and purging. Tincture of rhubarb, tincture of calumba, and tinc- 
ture of opium, make an effective remedy. One of the most generally 
useful and certain remedies for attacks of cholera morbus is chloro- 
dyne. As a secret, proprietary remedy it should not be prescribed, 
but one of the more accurately prepared imitations of the original 
compound can be substituted. There can be little doubt now that 
this is a fortunate combination of remedies, adapted to the treatment 
of gastro-intestinal maladies having the choleriform character. 

CHOLERA INFANTUM. 

Definition. — An acute gastro-intestinal catarrh, occurring in children 
during the period of the first dentition, and characterized by vomiting, 
purging, and considerable febrile excitement. It is also called summer 
cholera and " summer complaint " in domestic practice. 

Causes. — Early life — the first two years — owing to the various 
phases through which the organism is then passing, is the period for 
cholera infantum. Bad hygiene is the great factor — including damp, 
ill-ventilated, and confined houses, air contaminated by cesspool and 
sewer emanations, continuous high temperature, and improper food. 
Feeding infants the coarse food of adults, or confining them to a diet 
composed almost entirely of starch, are most fruitful causes of an out- 
break of the disease, the other conditions being present. This pe- 
culiar form of gastro-intestinal catarrh occurs chiefly in cities, in 
low, malarious localities, and is especially frequent on this side of 
the Atlantic. But Berlin has the bad preeminence, according to Lom- 



72 



DISEASES OF THE DIGESTIVE SYSTEM. 



bard,* of surpassing the American cities in " the frequency of the 
cholera of infants." Recent investigations tend to show that cholera 
infantum is caused by an infective organism — a specific microbe. It 
is in a high degree probable that these organisms or microbes gener- 
ate a peculiar poison — a ptomaine — to the action of which the phe- 
nomena of the disease are due. 

Pathological Anatomy. — The changes occurring in cholera infan- 
tum are those described under the general head of catarrh of the 
intestines. The implication of the solitary glands and the agminated 
(Peyer's) patches is somewhat more decided than is there stated, prob- 
ably, but otherwise the description there given is accurate. A marked 
degree of cerebral anaemia is represented in a venous stasis, and a good 
deal of fluid in the subarachnoid spaces. 

Symptoms. — This disease sets in by two modes of onset : with pre- 
liminary symptoms ; suddenly. Usually there are prodromes, the child 
becoming restless, irritable, feverish, before any bowel symptoms are 
manifest, then diarrhoea comes on, vomiting occurs, and the disease is 
fully developed. In other cases diarrhoea has persisted several weeks 
with the usual symptoms, and gradually the phenomena of cholera 
infantum are added. Again, the disease is suddenly developed : the 
child, in full health, is attacked, without any preliminary symptoms, 
with the characteristic vomiting and purging. The first evacuations 
contain more or less fecal matter, but soon the characteristic watery 
stools make their appearance. These are so thin as to soak into the 
napkin, leaving a greenish or greenish -yellow stain, and having an odor 
of rotten wood, or indeed having but little odor. With these stools 
are particles of curd, or undigested food passed as swallowed, or yel- 
lowish masses of mucus turning green on exposure. Simultaneously 
vomiting occurs of any food or drink swallowed, and with these mat- 
ters a quantity of sero-mucus, acid, neutral, or even alkaline, according 
to the time of the vomiting. Usually anything taken into the stomach 
— water or mother's milk — is rejected immediately ; the retching 
continues, and the mucus coming up after the food is acid ; further 
retching brings up some serous fluid, which is neutral, and alkaline 
if it comes from the duodenum. Prolonged retching brings up not 
only the contents of the duodenum, but mucus and bile from the gall- 
bladder. The loss by the gastro-intestinal mucous membrane induces 
rapid wasting. In a few hours the body shrinks remarkably, the eyes 
are sunken and half closed ; the mouth remains half open, the lips dry 
and cracked, and bleeding, for the infant feebly picks at the fissures ; 
the face is shrunken, pallid, with an occasional red spot in the cheeks. 
More or less pain is felt when the bowels are moved or when vomiting 
is about to take place, which the child manifests by restlessness and a 



* " Traite de Climatologie Medicale," vol. iv, p. 317. Paris : Bailliere et Fils, 1880. 



CHOLERA INFANTUM. 



73 



husky whine or cry. Tenderness on pressure usually exists along the 
track of the colon, and an erythematous rash diffuses from the anus 
over the buttocks and genitalia, causing so much tenderness that the 
contact of the irritating discharges excites pain. The mind is, how- 
ever, rather torpid, the senses not acute, and the attention roused only 
by strong excitation. The child lies at last in a condition of great 
exhaustion, indifferent to all surrounding objects, and experiencing 
the distress which comes from thirst only. 

Rise of temperature takes place with the first disturbance of the 
intestinal canal, the fever being of the remittent type, with the remis- 
sion in the morning, usually. In the early morning is the period of 
greatest depression. With the rise of temperature in the afternoon, 
the cheeks may be a little flushed, and the countenance, therefore, 
appear better. The range of temperature taken in the axilla is from 
102° to 104° Fahr. in the pronounced cases. The pulse is very rapid 
and feeble — 140 to 160 beats in the minute. The number of dis- 
charges may rise to forty or fifty a day, many of them not more than a 
teaspoonful of fluid. With the progress of the case, there is a rapid 
decline in weight and strength ; the pulse becomes more quick and 
feeble ; the respirations grow more and more shallow, and hypostatic 
congestion and oedema occur ; carbonic-acid poisoning ensues, with a 
gradually deepening coma, ending in death. 

Course, Duration, and Termination. — The ordinary course is prompt 
in the fatal tendency, or toward cure, the latter being the natural ten- 
dency when the child is put under favorable hygienic conditions. The 
duration of the attack proper is two or three days to one week ; severe 
cases may terminate in collapse in a day or two. When recovery en- 
sues, the duration of the case is prolonged by the subsequent ileo-colitis. 
If the prodromic symptoms are included, it may be said that the aver- 
age cases are from one to two weeks, not including the ileo-colitis or 
the proctitis, which may prolong the attacks several weeks. The most 
frequent termination is by exhaustion and death by coma from defi- 
cient excretion of carbonic acid and its accumulation in the blood. 
The cerebral anaemia may be confounded with acute cerebral conges- 
tion, and the death attributed, very erroneously, to the latter. Death 
may happen at the lungs or from failure of the heart. 

Diagnosis. — The only disease with which cholera infantum can be 
confounded is true cholera, but, as the therapeutical indications are the 
same, it is the less important to be correct. 

Prognosis. — A guarded opinion should always be given, as the case 
may very unexpectedly take an unfavorable turn. The hygienical 
surroundings influence the prognosis greatly. The number and fre- 
quency of the discharges and the readiness with which the symptoms 
yield to the treatment are important elements in making up a judg- 
ment. The constitutional condition, the inherited tendencies, and the 



DISEASES OF THE DIGESTIVE SYSTEM. 



aliment available for nutrition, are to be carefully considered. When 
the child is at the breast, and the supply of milk is abundant and good, 
the prognosis may be more favorable than if the child has been 
weaned, and the kind of aliment suitable to the case remains un- 
determined. 

Treatment.— Immediate attention must be given to the aliment. 
Instead of large draughts of water, the child should suck some pieces 
of ice. If nursing, the number and duration of applications to the 
breast must be regulated. The child is excessively thirsty, and is in- 
cessant in the demands for nursing. The stomach is quite unable to 
dispose of it, and it is either soon rejected or passes by the bowels. 
Once in two, two and a half, or three hours, according to the age, is 
often enough, and the child should be removed when it has obtained 
the amount which can be retained by the stomach. If fed by cow's or 
goat's milk, this should be diluted with lime-water. If they do not 
agree, owing to an inability to digest the casein, which is the usual dif- 
ficulty, the best substitute is barley-water, of the density of good milk, 
to which cream is added in the proportion in which it exists in milk. 
This combination is a nutritious aliment of the quality of milk, less 
the casein. Beef-tea is vory badly borne in these cases, and the artifi- 
cial foods prepared for infants are not, in the author's experience, good 
substitutes for milk. One of the most important remedial agents is 
the cold bath. The extraordinary temperature range, almost reaching 
hyperpyrexia, is an important element of danger, causing failure of the 
heart and paralysis of the brain. The cold bath is the most effective 
means of combating the fever. The child must be very gently and 
carefully immersed in water at 95° to 100° Fahr., and the cold water 
gradually added until the thermometer stands at 85° or 80°, or even 
60°, if well borne. The duration of the bath is about ten minutes, and 
the frequency of their repetition depends on the influence which they 
have on the temperature. Two or three baths per day are required 
until the fever permanently declines. 

The administration of pure cognac brandy, in a small quantity of 
very cold water, is an excellent means of checking the vomiting and 
purging, and of lessening the abnormal heat. From twenty minims to 
one drachm every two, three, or four hours, according to the age of 
the subject and the severity of the symptoms, is the proper amount 
for administration. The opium so much prescribed, and so remarkably 
beneficial in cholera morbus — a similar state in the adult — is a remedy 
whose utility is most questionable. In the author's judgment, opium 
should be given only when the other means used have no effect in re- 
straining the excessive discharges. A most efiicient prescription is the 
combination of bismuth and carbolic acid — ten grains of the former, 
and one fourth to one half grain of the latter, every two hours. It is 
best administered with some tincture of cinnamon in an emulsion of 



DUODENITIS. 



75 



gum-arabic. It may be given also with mistura cretse. Resorcin has 
been used successfully in the same condition of things requiring car- 
bolic acid. Rhubarb, in doses that are merely astringent, with an 
aromatic (cinnamon) and an alkali (bicarbonate of potassium), is an 
efficient remedy, especially in this combination. Infusion of rhubarb, 
tincture of cinnamon, with some bicarbonate of potassium, makes a 
disagreeable but extremely serviceable prescription in these cases. 
Oxide of zinc, oxide of silver, nitrate of silver, are useful in those cases 
characterized by severe watery purging rather than vomiting. When 
the vomiting is excessive, and other medicines are rejected, calomel 
is extremely beneficial, and, indeed, in ordinary cases, it has the first 
position almost as a sedative to the gastro-intestinal mucous membrane. 
It must be given in very small doses — one twentieth to one tenth of a 
grain, every half hour or hour. It may be rubbed up with some sugar 
of milk and dropped on the tongue. When there is much straining, 
and especially if there be much mucus,- and mucus streaked with blood, 
passed from the bowels, minute doses of arsenic (from one eighth 
to one fourth drop of Fowler's solution) with a little opium (one 
fourth to one half of a drop), every three hours, are very serviceable, 
and, under the same conditions, very small doses of corrosive sub- 
limate (yJq- gr.) may do great good. If the discharges are very pro- 
fuse, watery, and not restrained by the remedies prescribed by the 
stomach, enemata of starch and laudanum may be used. Counter- 
irritation by mustard (the skin very little reddened or irritated), or 
by means of a spice-bag, or, better, a turpentine-stupe, is beneficial, if 
not carried too far. 

When the algid stage approaches, nitro-glycerin, amyl nitrite, and 
atropine, may be most effective in reviving the failing circulation. 



DUODENITIS— CATARRH OF THE DUODENUM. 

Definition. — Catarrh of the mucous membrane of the duodenum 
may be acute or chronic. As the ductus communis choledochus opens 
into that part of the canal, the catarrhal process extends up by con- 
tiguity of tissue, and hence catarrhal jaundice may coexist with duo- 
denitis. 

Etiology. — Climatic changes are very influential in setting up a 
catarrh of the duodenum. External irritation, if severe and prolonged, 
will cause hypersemia and structural changes, just as a severe burn will 
excite ulceration. Probably the most common cause is indigestible 
aliment, which passes the stomach unchanged, and the excessive use 
of starchy, saccharine, and fatty foods, which require for their diges- 
tion and absorption the action of the intestinal juices, of the bile, and 
of the pancreatic fluid. 



76 



DISEASES OF THE DIGESTIVE SYSTEM. 



Pathological Anatomy. — The general description already given ap- 
plies here. Hyperaemia and osdema occur to a more pronounced extent 
about the orifice of the common bile-duct, which is so swollen as to 
encroach materially on the lumen. More or less injection and swelling 
of the mucous lining of the duct exist to a variable extent. 

Symptoms. — The anatomical seat of the inflammation influences, to 
a great extent, the symptoms. In other cases of intestinal catarrh, 
diarrhoea is a prominent symptom ; in duodenitis, diarrhoea is excep- 
tional, and more or less constipation is the rule. Pain and disor- 
ders of digestion are usually present, and jaundice is a j^rominent 
symptom. 

The pain is felt in the right hypochondriac and umbilical regions, 
and soreness can be developed by deep pressure over the duodenum. 
The pain is not usually very acute — the sensation is compounded of 
pain and soreness, but occasionally severe pain occurs in the hepatic 
plexus. As in catarrh of the stomach there are occasional attacks of 
gastralgia, so in catarrh of the duodenum there are occasional attacks 
of hepatalgia. The paroxysms of severe pain come on gradually, and, 
after some hours, gradually subside. There is no increased soreness 
during the existence of the pain or subsequently. 

There may or may not be present gastric catarrh, as well as duo- 
denitis. The distress caused by the presence of food is felt about 
three hours after it has been taken, and is usually referred by the 
patient to the seat of the disease. The starchy and saccharine ele- 
ments of the food undergo fermentation, and hence, in about three 
hours after they have been swallowed, the formation of flatus begins, 
the small intestines become distended with gas, and some pain, due to 
the stretching of the bowel, is felt about the umbilicus. From the 
third to the seventh day jaundice appears. It is usually announced by 
a coated tongue, fetid breath, and yellowness of the conjunctiva, head- 
ache, stupor, and hebetude of mind (cholsemia), with depression of 
spirits. The yellowness extends, and in a short time the jaundice is 
universal. The absorption of bile is coincident with swelling of the 
common duct, and entire absence of bile in the intestinal canal. The 
stools now have a pasty consistence, a slate-color, and fetid odor. 
Gas, discharged previously, had but little odor ; after the jaundice, 
it has the same fetid character as the stools. The urine is thick 
from excess of urates, and of a deep-brownish color from presence 
of bile-pigment. When the jaundice has attained the maximum, 
there are complete anorexia, nausea, sometimes vomiting of food, 
mucus, sero-mucus, and constipation, although diarrhoea may occur ; 
but instead of jaundice there may be merely the condition of bilious- 
ness. The temperature is slightly elevated — 99 '5° Fahr. in the 
morning and 100° to 101° Fahr. in the evening. The pulse corre- 
sponds. 



DUODENITIS. 



Course, Duration, and Termination. — The disease is self-limited, 
and, if permitted to pursue its course uninterrupted, will last two or 
three weeks, leaving the patient much debilitated. In malarious dis- 
tricts this malady is exceedingly common, and may be intimately 
associated with malarial infection. The chronic form of duodenitis 
is essentially the same in respect to clinical history and characters, 
except as to duration and violence of the symptoms, as the acute form. 
The duration of the chronic form may be several months. The late 
researches of Charcot and Legg have demonstrated that long-continued 
obstacle to the outflow of bile leads to structural changes in the liver. 
The termination of uncomplicated duodenitis is in health. The acute 
is apt to pass into the chronic form, and the latter to affect the hepatic 
parenchyma in the manner to be hereafter described. Hepatic colic 
is also one of the results of this disease. 

Diagnosis. — Duodenal catarrh may be confounded with gastric 
catarrh, with hepatic colic, and with diseases of the liver proper, ac- 
companied by jaundice. As respects gastric catarrh, the differentia- 
tion is to be made by reference to the seat of pain and soreness, the 
time when the distress from the presence of food comes on, the occur- 
rence of flatulence with bowel-pain, and especially the appearance of 
jaundice at a certain time after the beginning of the symptoms. Duo- 
denal catarrh is separated from hepatic colic by the following signs : 
In the latter, the pain comes on suddenly after some pain and sore- 
ness in the region of the gall-bladder, and radiates from this point 
over the abdomen ; the pain is so intense as to produce a cold sur- 
face, a weak pulse, great depression, and incessant vomiting ; the 
pain suddenly ceases, and there is complete relief, except some local 
tenderness ; jaundice follows these symptoms, but disappears in a few 
days, leaving the patient well ; and a gall-stone may be found in an 
evacuation a few days after the attack. Hepatalgia is a neuralgic at- 
tack, occurring suddenly, and limited to the hepatic plexus. It ceases 
suddenly, leaving the patient well, and the only interference with 
function is during the existence of pain. Its duration is but a few 
hours. 

Treatment. — The first point is regulation of the diet. The diet 
should be restricted to those substances convertible into peptones in 
the stomach, as milk, whey, buttermilk, eggs, animal broths, and all 
saccharine, starchy, and fatty constituents should be avoided. Fresh 
meats, game, poultry, and fish, without butter or fat, are admissible if 
the stomach is equal to their digestion. The most rapid progress can 
be made by adhering to an exclusive diet of milk, and, as there is com- 
plete anorexia, this is usually not difficult. The hypersemia of the 
duodenal mucous membrane is relieved by saline laxatives, by the 
Saratoga, Carlsbad, or Vichy waters, by Rochelle salts, but especially 



78 



DISEASES OF THE DIGESTIVE SYSTEil. 



by phosphate of soda, which should be given in drachm-doses about four 
times a day. Other remedies, acting similarly, are sulphate of mag- 
nesia and bitartrate of potassa. The general principle is to use reme- 
dies which will promote an outward diffusion, and thus relieve the 
congestion and oedema of the mucous membrane. Small doses of calo- 
mel grain to one grain) may be highly useful as a sedative and anti- 
ferment, and acting in the same way are bismuth, oxides of silver and 
zinc, but especially the purified black oxide of manganese. Active 
cholagogues, as the resin of podophyllin, rhubarb, aloes, etc., are to 
be avoided on account of the irritation which they induce. Excellent 
results are had from the benzoates — the benzoates of sodium and am- 
monium, especially the latter. Benzoate checks fermentation in the 
duodenum, lessens stasis in the portal system, and promotes elimina- 
tion by the kidneys. To rouse the liver — a favorite phrase — is out of 
place here, since the obstacles to the outflow of bile are merely me- 
chanical. When malarial infection coexists, quinine is indispensable 
to restore health. Without any complication of malaria, quinine has 
a good effect, and hastens the disappearance of the jaundice. When 
the bile enters the intestine and the intestinal digestion is restored, the 
jaundice may still linger. Diuretics and purgatives may then be em- 
ployed to remove the last traces of bile-pigment. 



ILEITIS— ILEO-OOLITIS— CATARRH OF THE ILEUM AND OP 
THE ILEUM AND COLON. ACUTE DIARRHCEA ; CHRONIC 
DIARRHCEA. 

Definition. — Ileitis is a catarrh of the ileum, either acute or chronic ; 
ileo-colitis is a catarrh involving both parts — the whole extent of the 
ileum and the csecum and ascending colon. This may also be either 
acute or chronic. The disease is frequently denominated diarrhoea, 
from a single symptom. 

Causes. — The causes already given for other forms of intestinal 
catarrh are equally true of this form. The two great factors are im- 
proper and indigestible food and the summer temperature. An attack 
may be brought on by exposure to cold and damp air when in a per- 
spiring state. The sudden arrest of cutaneous transpiration precipi- 
tates a vicarious duty on the mucous membrane, with the effect to 
induce a general hypersemia of the ileum and colon. As respects chil- 
dren, the causes in operation to produce ileo-colitis are the same as 
those which bring on cholera infantum. 

Pathological Anatomy. — In this variety of intestinal catarrh, the 
morbid anatomy has the special feature of enlargement of the agmi- 
nated patches, which are most abundant and most highly developed in 



ILEO-COLITIS. 



79 



the lower ileum. The condition of the epithelium, of the villi, and of 
the glands, has been described. Sufficient emphasis has, probably, 
not been put on the tendency of the swollen glands to ulcerate. In 
the acute cases the orifices of the solitary glands are here and there 
eroded ; but in the chronic cases considerable ulcers form. These 
changes are different in character and very different in extent from 
those which take place in typhoid. 

Symptoms. — The acute form of ileitis or ileo-colitis sets in with 
some chilliness and general malaise, followed by feverishness. Pain 
in the abdomen, usually about the umbilicus, is felt, and then loose 
evacuations begin. The number of stools each day varies with the 
character of food and the extent of the disease, especially in the colon. 
It would be a mistake to suppose that the diarrhoea is due solely to an 
irritation of the affected portions of the mucous membrane by the 
particles of aliment reaching them. Considerable transudation occurs 
as one result of the hypersemia : cast-off epithelium, young cells, and 
minute sloughs mix with the serum, and constitute no small part of 
the stools discharged. Besides, the chyle imperfectly prepared for 
absorption, and hurried down the canal by the increased peristalsis, 
and the fatty, starchy, and saccharine constituents of the food, fer- 
menting instead of digesting, unite to form the liquid discharges char- 
acteristic of ileo-colitis. As might be expected, there is little fecal 
matter proper, and the stools have a yellow or greenish-yellow color, 
and, if the evacuations have been very copious, they may be whitish, 
like the " rice-water " discharges. In children the stools have a some- 
what different character, owing to the presence of casein, which pre- 
sents an appearance of putty, or the casein occurs in small, irregular 
masses. Very often the stools have a bright-green color, or become 
green on exposure. Just before the evacuation considerable pain is 
experienced, and, in children, nausea and vomiting also. The pain is 
usually increased by pressure, and soreness is developed at any time 
by deep pressure. As gases are freely generated in food decompo- 
sitions, the intestines are often suddenly distended, giving rise to 
pains as of flatulent colic. Borborygmi are more or less present. It 
is a curious fact that mental depression is a very constant condition in 
cases of ileo-colitis when there is abundant production of gas. The 
digestion and assimilation of food being almost arrested, and great 
waste taking place by the intestinal mucous membrane, it is obvious 
that the organism must lose ground rapidly. The subcutaneous fat 
disappears ; the muscles shrink and lose their contractile energy ; the 
skin becomes dry, sallow, and wrinkled ; the action of the heart is 
weak, the pulse small and feeble ; the urine is acid, high-colored, 
and burning. Children affected with summer diarrhoea, and hav- 
ing from three to six evacuations a day and vomiting occasionally, 



80 



DISEASES OF THE DIGESTIVE SYSTEM. 



rapidly emaciate, are reduced to a skeleton in fact. In the adult 
the chronic form is known as " chronic diarrhoea," in which, as is well 
known, the wasting of the tissues of the body proceeds to the lowest 
point. 

Course, Duration, and Termination. — In the simplest cases of ca- 
tarrh of the intestine, due merely to an unusual accumulation of faeces 
— crapulous diarrhoea — the looseness of the bowels is conservative, an 
effort of nature to be encouraged rather than restrained. In mild, un- 
complicated cases the tendency is to recovery in a few days, but in the 
severe cases the duration may be several weeks. In the chronic form 
the duration is indefinite. The acute runs insensibly into the chronic 
form, and there is no well-marked distinction, except the element of 
time. 

Diagnosis. — The distinctions to be made are between duodenal 
catarrh and catarrh of the rectum (proctitis). In children, ileo-colitis 
is to be distinguished from cholera infantum. In duodenal catarrh 
there is little or no diarrhoea, and jaundice appears in a few days, 
symptoms entirely different from ileo-colitis. In proctitis the stools 
may be normal, or occur as scybala. There are straining, heat, and 
irritation about the rectum, and the discharge of mucus, and mucus 
and blood. In children, ileo-colitis is frequently mistaken for and 
called cholera infantum. The latter is a disease of sudden onset, 
characterized by choleriform symptoms and a duration of a few days 
or few hours only. The character of the discharges is essentially 
different ; in ileo-colitis they contain casein, yellowish or greenish 
liquid matter, spinach-colored masses ; whereas, in cholera infan- 
tum, they are serous in character, colorless, like the so-called rice- 
water evacuations, and do not leave anything but a stain on the 
napkin. 

Prognosis. — In acute diarrhoea, under good hygienic conditions, 
the prognosis is favorable. In children, summer diarrhoea is amenable 
to treatment or not, according to the condition in life, and the ability 
of parents to provide the necessary means. When ileo-colitis has be- 
come chronic, and is not readily amenable to the treatment, the prog- 
nosis is grave. In adults, for chronic diarrhoea, which has long existed, 
the prognosis must be guarded. 

Treatment. — In simple acute catarrh relief is afforded by a pill of 
opium and camphor. When the evacuations are numerous and pro- 
fuse — summer diarrhoea, for example — the most efficient treatment is 
the combination of a mineral acid (muriatic or sulphuric) with tinc- 
ture of opium. Carefully managed, the same remedies may be ad- 
ministered to infants. Sometimes alkalies agree better. Sodium bi- 
carbonate can be given with or without bismuth in chalk-mixture. 
Alkalies, however, merely neutralize acids, but the mineral acids check 



TYPHLITIS. 



81 



the fermentation on whicli the production of acid depends. When 
the discharges are greenish ("chopped spinach"), the combination of 
arsenic and opium is highly efficient — for example, one drop of Fow- 
ler's solution, and one drop or less of the deodorized tincture of opium. 
When there are retained matters, the presence of which excites irrita- 
tion, an emulsion of castor-oil, with two or three drops of turpentine 
and some tincture of opium, is very advantageous. In the more 
chronic cases, or after the acute symptoms have subsided, sulphate 
of copper with a little opium is an admirable remedy — from one 
thirtieth to one twelfth of a grain of copper sulphate, and one fortieth 
to one sixth of a grain of morphine, according to the age of the subject. 
Other astringents, metallic and vegetable, may be employed under the 
same circumstances. For children, bismuth is probably the best 
astringent. Resorcin has been found to be an effective remedy. Ergot 
has now and then proved a valuable expedient, and in some cases, 
especially of the more chronic kind, cubeb, eucalyptus, and others of 
this group, have rendered important aid. Regulation of the diet is 
even more important than the use of medicines. The starchy, fatty, 
and saccharine articles of food are highly objectionable, and should 
be omitted entirely, as already advised. The same plan of diet sug- 
gested in previous articles is applicable here, and need not, therefore, 
be repeated. 



TYPHLITIS — INFLAMMATION OP THE OiECUM.— CATARRH OF 

THE OJGCUM. 

Definition. — The term typhlitis is restricted to an inflammation of 
the C£ecum and its appendix. Perityphlitis is an inflammation taking 
place in the loose connective tissue on which the csecum rests. Al- 
though the seat of the lesion and its nature are very different, it is 
necessary, because of their intimate relations, to consider them to- 
gether. 

Causes. — Besides the causes of catarrh of the intestines already suf- 
ficiently set forth, there are special conditions affecting the caecum. 
The anatomical position of this organ as a receptacle for the small in- 
testine, the arrangement of its muscular elements, the abundant folds 
of mucous membrane when empty, and its immense capacity when 
filled, are properties necessary to its function, but at the same time 
causes of disease. 

Pathological Anatomy. — Catarrh of the caecum may exist as a mere 
catarrhal affection of the mucous membrane, with the changes in the 
epitheliam, in the solitary glands, and in the vessels already described ; 
or as a localized inflammation, usually from the presence of a foreign 
8 



82 



DISEASES OF THE DIGESTIVE SYSTEM. 



body, terminating in ulceration ; or as an inflammation of the caecum 
in general, with a more intense action about the ileo-cascal valve, and 
implication with thickening of the submucous connective tissue, causing 
stenosis. The second or ulcerative form of catarrh of the csecum will 
be described hereafter under ulcers of the intestinal canal. The last- 
named variety remains for consideration. The ileo-coBcal valve being 
more exposed to injury than any other part of the caecum, owing to its 
position and office, is more liable to be invaded by disease. When a 
catarrh of the caecum exists, especially the chronic form, the hyperte- 
mia and swelling are more decided in the neighborhood of the orifice. 
An extension of the inflammation to the submucous layer occasionally 
takes place, the connective tissue undergoes hyperplasia, a permanent 
increase of thickness results, and stenosis is an ultimate effect of the 
changes. It is only in the chronic form that such thickening and ste- 
nosis can occur. 

Symptoms. — There are two forms of catarrh of the caecum — the 
acute and chronic. Of the acute variety there are various grades in 
the severity of the cases, but two are sufficiently defined to require 
attention — the mild and the severe. In the mild cases, uneasiness, 
followed by pain and soreness, is felt in the right iliac region, extend- 
ing up along the course of the ascending colon. On palpation, ten- 
derness is found to exist in this region, and laterally just above the 
crest of the ilium. The more decided the pressure, the more distinct 
the pain. Early, and before the inflammation has extended beyond the 
mucous layer of the caecum, the decubitus and the sitting posture are 
characteristic — the body is turned toward the right side, and is flexed 
somewhat to relax the muscles on the right lateral plane. Additional 
soreness is experienced when the body is held erect, or straightened 
out in bed. With the first symptoms there may be some accumulation 
of faeces, and the caecum and ascending colon may be distinctly bulging 
and prominent, so that they may be recognized on inspection ; but in 
the mild cases there is no impaction, properly speaking, but on careful 
palpation the outline of the bowel can be made out, feeling rather 
soft and dough-like. The bowels are usually constipated, for catarrh 
of the caecum seems to affect the muscularis, impairing its contractile 
energy, or there may be an appearance of relaxation by reason of an 
accumulation in the sacculated periphery of the bowel — leaving a cen-j 
tral cavity along which the liquid contents of the small intestines may 
pass. The author has seen several examples of this, and so important 
is the recognition of the condition that he now desires to emphasize 
the fact. During the development of these local symptoms, the sys- 
tem partakes in the disturbance. The attack sets in with general 
malaise, some feverishness, a coated tongue, loss of appetite, nausea, 
and not unfrequently vomiting. In the severe cases the symptoms 



TYPHLITIS. 



83 



are increased in severity in all directions. The local pain, tenderness, 
and swelling are greater, there are impaction of fseces and no move-^ 
ment. There are decided fever, considerable restlessness, nausea, and 
vomiting. The vomited matters consist at first of the contents of the 
stomach, then of the duodenum with much bilious matter, and ulti- 
mately, if the impaction persist, of matter that has somewhat the odor 
of faeces. With the development of the case there occurs great de- 
pression of the powers of life, the face becomes pinched and anxious, 
the skin covered by a clammy sweat, the pulse small and rapid, the 
action of the heart weak. Peritonitis is finally developed by con- 
tiguity of tissue, or by the bowel giving way at some point, weak- 
ened by ulceration. The subsequent history is then the history of 
peritonitis. 

In the chronic cases, which may succeed to the mild acute, or, 
as is much more comft^n, develop slowly by the operation of the 
ordinary causes of intesunal catarrh, the symptoms are those of intes- 
tinal indigestion. There is uneasiness in the region of the ileo-caecal 
valve, flatus is felt passing the orifice, and the patient is often con- 
scious of the difference in density, whether gas, liquid, or solid, of the 
materials passing the orifice. The bowels are confined and rather dif- 
ficult to move. When the actions are free, serai-solid, and unirritating, 
the patient has a keen sense of relief. Rarely, on careful palpation, 
induration, not hard like that of scirrhus, but doughy, can be made 
out. A comparatively empty state of the large intestine and disten- 
tion of the small intestines can usually be ascertained ; in that event 
the lateral portions of the abdomen are rather flat, and the central part 
around the umbilicus is prominent. 

Course, Duration, and Termination.— The mild form of acute ca- 
tarrh of the caecum, if properly managed, is readily cured in a week 
or two. The severe form may terminate by acute peritonitis within a 
week, or be relieved, and all pain and tenderness subside, within two 
or three weeks. Very frequently entire recovery does not ensue, but 
the case passes into chronic catarrh, the duration of which is very in- 
definite ; or, associated with perityphlitis, a chronic abscess may con- 
tinue in a torpid state for some time, or a fistulous communication be 
established with the exterior. Abscess of the liver is a frequent result 
of catarrhal inflammation and ulceration of the caecum. 

Diagnosis. — It is often extremely diflicult to distinguish typhlitis 
from perityphlitis or from occlusion of the bowel by other kinds of 
obstruction. The points of difference between typhlitis and perity- 
phlitis can be better understood after the study of the latter, and are 
therefore reserved. Typhlitis in the mild form is distinguished from 
other affections of the bowel by the local pain and soreness, by the 
fullness without impaction ; in the cevere form, the symptoms of 



84 



DISEASES OF THE DIGESTIVE SYSTEM. 



obstruction are the same as in other kinds of occlusion, but the local 
pain and the distinct enlargement of the bowel indicate the existence 
of an inflammation and fecal obstruction of the caecum. In these af- 
fections, the decubitus of the patient is an important aid to diagnosis. 
Chronic catarrh of the caecum is recognized by the locality of the dis- 
tress. As cancer of the caecum behaves in the same way in the early 
stage of its formation, there may be no means of differentiating ; but, 
in the progress of the case, the growth of a nodulated tumor, the pro- 
gressive increase in the pain and obstruction, and the development of 
a cachexia, are sufficient to indicate the nature of the affection. 

Prognosis. — In the simple form the prognosis is favorable ; in the 
severe form it is grave, although recovery will ensue in a large pro- 
portion of the cases if the management is judicious. In the chronic 
form, when the connective tissue has become thickened, the prognosis 
as to cure is unfavorable. 

Treatment. — In the treatment of acute typhlitis all active purga- 
tives must be avoided. If there is but little feverishness, and the 
local tenderness is slight, saline laxatives may be administered from 
the beginning, in small doses at short intervals, to induce liquefaction 
of the contents of the bowel. The hyperaemia is lessened by the same 
means. When free discharges are obtained in this way, the canal 
should be kept quiet with opium for a few days. The most efficient 
and, at the same time, safe laxative is sulphate of magnesia. It is a 
curious fact that this salt will be retained when other salines are re- 
jected by vomiting. Rochelle salts may be used as a substitute when 
Epsom salts is not suitable. Different management is required in cases 
of typhlitis with impaction and arrest of the intestinal movement. If 
there be fever and much tenderness, no attempt should be made to 
relieve the bowels by purgatives of any kind. It is in this condition 
of affairs that opium in some form, especially in the form of the hypo- 
dermatic injection of morphine, is so serviceable. The patient should 
be kept thoroughly under the influence of the narcotic. It is better to 
combine atropine with the morphine, for greater security and increased 
therapeutical power. No absolute rule for quantity can be laid down, 
but the decided effects of morphine, as shown in the state of the pupil, 
the pulse, the respirations, and the somnolence, should be steadily 
maintained. The fullest curative power of morphine is obtained from 
a quantity strictly within the limits of safety, and hence no risk need 
be had to obtain the best results. As a guide to the administration, it 
may be stated that one fourth of a grain of morphine and ywo gi'^in of 
atropine is enough for the first dose in an adult, and subsequently one 
eighth of a grain of morphine and grain of atropine may be given 
every four, six, or eight hours, according to the effect. If there be any 
reason, moral or physical, which prevents the hypodermatic adminis- 



TYPHLITIS. 



85 



tration, the next best mode is the rectal injection of the tincture of 
opium. As respects the quantity, the rule above given is proper ; it is 
the degree and constancy of the effect which determine the amount. 
If the rectal injection is objected to, or the organ is intolerant, opium 
must be administered by the stomach. The best preparation is the 
deodorized tincture, and, to secure uniformity in action, the preparation 
made after an essay of the opium is altogether preferable. This cor- 
responds in strength to laudanum : sixty drops may be the first dose, 
and twenty drops every two, three, or four hours succeeding, the quan- 
tity to be determined by the effects, as already insisted upon. The 
administration of the opium is to be continued until the bowels are 
moved spontaneously, or until the inflammatory action — the fever and 
local tenderness — subsides. The effects may be maintained for several 
days, for a week or more. As soon as the tenderness subsides, the 
saline laxative may be then given, in the cautious way already advised 
— a teaspoonful of Epsom salts in two ounces of water every three 
hours. With the subsidence of the local tenderness and heat, the 
quantity of opium can be slowly reduced and the interval between the 
doses lengthened. If the vomiting be persistent, it may be relieved 
by milk and lime-water (three parts to one), carbolic acid (gr. ss. in 
cherry-laurel water), hydrocyanic acid (^iij), iced champagne, pellets 
of ice, etc., but when the hypodermatic injection is practiced vomiting is 
a much less pronounced symptom. In robust subjects, and in all cases 
not characterized by great debility, leeches should be applied at the 
seat of tenderness, and in numbers according to the state of the patient 
— from two to ten to be allowed to fill and drop off, and the bleeding 
be then arrested. Good effects are obtained from counter- irritation by 
mustard, followed by fomentations of turpentine, or turpentine stupes, 
and hot poultices, when heat applications are useful. According to 
the author's observation in these cases, the external application of ice 
— in the form of an ice-bag — is more efficient than warm applications. 
In the severe cases of typhlitis, when the time has arrived for attempts 
to remove the impaction, the action of the saline laxative may be aided 
by irrigation of the bowel. It is now known that by this method the 
bowel may be filled with fluid up to the ileo-caecal valve. Accordingly, 
repeated efforts by enemata of warm soapsuds should be made to 
soften the masses of hardened faeces which so effectually block the 
canal. The use of a long rectal tube to convey the fluid beyond the 
sigmoid flexure facilitates the operation materially. If impaction has 
existed for several days, care must be used in distending the bowel, 
for it may yield to the pressure, softened it may be by an inflamma- 
tory process involving all the layers. Lately it has been found that 
irrigation of the stomach, as practised in stomachal diseases, is an 
effective means of relief in cases of impaction of the intestine. 



86 



DISEASES OF THE DIGESTIVE SYSTEM. 



INFLAMMATION OF THE APPENDIX VERMIFORMIS The 

usual cause of inflammation of the appendix is the lodgment of an 
intestinal concretion, grape-seed, or other foreign body.* Cases of 
inflammation, apparently catarrhal, do, however, rarely occur, and very 
serious symptoms quickly arise by extension of the disease to the peri- 
toneal layer. The symptoms are the same as those of the severe form 
of typhlitis, with some important exceptions to be presently detailed. 
The appendix differs from the csecum in that it has an entire perito- 
neal investment, and in that it is free except its point of connection 
with the caecum. In some subjects the appendix is two inches in 
length, and hence dips down into the iliac region to the pelvis, and 
reaches almost or quite to the bladder. When, therefore, an inflam- 
matory process occurs in it, the tenderness and pain are felt in the iliac 
region as low down as Poupart's ligament, and not in the caecum. 
When typhlitis exists, the appendix becomes involved, but death may 
and does frequently follow from disease of the appendix, without the 
caecum being implicated. When, therefore, this form of typhlitis 
occurs, besides the symptoms already set forth, there is pain in the 
groin, extending down the course of the anterior crural, and through 
the hip. The tenderness is usually exquisite, and the slightest at- 
tempt at palpation gives the patient great dread. The thigh is 
flexed on the pelvis, and all attempts to extend it cause great suffer- 
ing. There is no fecal tumor such as is found in typhlitis with im- 
paction, and the bowels are not affected, but all intestinal movements, 
as the passing of gas through the ilio-csecal valve, cause pain. Peri- 
tonitis, much more readily than in affections of the caecum, occurs 
in inflammation of the appendix. It is often entirely local, and, 
adhesions forming, the morbid action is cut off from the general cavity 
of the abdomen. This is one of the modes by which fecal abscesses 
are formed. This subject and peritonitis are properly topics for 
future consideration. 

PERITYPHLITIS.— As the term indicates, this is an inflammation of 
the tissue about the caecum — really, of the connective tissue in which 
the cEecum is in part imbedded. This may arise spontaneously — an 
inflammation of the connective tissue — by the ordinary causes of such 
inflammation, especially trauma. It may be caused by the extension 
of inflammation from the caecum, by perforation of the caecum. Its 
special tendency is to suppuration. When well developed there is a 
hard, brawny swelling felt above the crest of the ilium, extending 
back into the lumbar region. There is not usually acute pain, but a 

* See cases reported by the author in his paper on typhlitis, in the " American Jour- 
nal of Medical Sciences," October, 1866, p. 851. 



PROCTITIS. 



87 



feeling of weight, soreness, with paroxysms of subacute pain, extend- 
ing into the hip, thigh, and abdomen. There is no necessary interfer- 
ence with the bowel, unless typhlitis and perityphlitis coexist. The 
development of the swelling is comparatively slow, but it attains con- 
siderable dimensions. Suppuration is preceded by an increase of the 
local distress ; when it has actually taken place, the tension and throb- 
bing diminish for a time, to increase again as the pus nears the sur- 
face. The formation of matter is attended by the usual constitutional 
symptoms. 

The treatment of perityphlitis is the same as that of typhlitis, 
except as regards the special attention given to the bowels, and en- 
tirely the same if the two maladies coexist. When pus forms in 
perityphlitis, and when a sero-purulent collection is formed by a lim- 
iting inflammation, in inflammation or perforation of the appendix, 
there arises the surgical question of an operation for the evacua- 
tion of the matter. By the use of the aspirator, the question of 
suppuration may be early determined. It is no doubt sound practice 
to pursue the method of Buck, and procure the evacuation of pus by 
a sufficient opening for free drainage.* 

CATARRH OF THE RECTUM.— PROCTITIS AND PERIPROCTITIS. 

Definition. — Catarrh of the rectum is known as proctitis. In the 
mild form it is the simplest kind of dysentery. In the severe form, as 
in the caecum, there may be impaction of the colon at and above the 
sigmoid flexure. The two forms correspond to the same conditions 
in the cajcum. The analogy becomes the more complete by reason 
of periproctitis — an inflammation of the connective tissue about the 
rectum. 

Causes. — Proctitis arises chiefly from constipation. Prolonged 
retention of hardened faeces sets up an irritation for their expul- 
sion. It is also caused by cold and dampness combined, especially 
sitting on the ground while in a perspiring state. Distention of 
the haemorrhoidal vessels, by obstructive disease of the liver, as in 
cirrhosis, is an occasional cause, but the disease then is quite masked 
by the more important results of the cirrhosis. The habitual use 
of stimulating enemata and of aloetic purgatives is a fruitful source 
of proctitis. 

Pathological Anatomy.— The alterations of structure are the same 
as those already described. 

Sympto^ns. — There are an acute and chronic form, the symptoms of 
which differ in degree merely. The acute variety exists in two forms, 

* " New York Medical Journal," vol. ii, p, 38. Numerous cases have been reported 
of some foreign body discharged by a fecal abscess. Hence, the need of a free opening. 



88 



DISEASES OF THE DIGESTIVE SYSTEM. 



the mild and severe. In tlie mild form of proctitis, the patient experi- 
ences a sense of uneasiness in the rectum — a burning, with desire to 
go to stool. There is much straining, and only mucus passes. The 
sphincter ani is in a constant state of spasm. Immediately after the 
passage of some mucus, there is felt considerable burning pain, and a 
sensation as if something remained, so that the patient returns again 
and again to the close-stool, and as before passes only some mucus or 
mucus mixed with blood. This condition is called tenesmus. The 
pain radiates from the rectum to the hips and back, and a feeling of 
depression and anxiety, and often of nausea, accompanies it. The 
colon is distended above the sigmoid flexure, but only some hard, 
roundish masses of fteces, known as scybala, descend occasionally. In 
the severe form all of these symptoms are intensified, the pain is very 
acute, intensely burning, and widely diffused. The straining is violent, 
and prolapse of the mucous membrane takes place, the sphincter ani 
closes over it spasmodically and the protruding portion becomes exces- 
sively painful, purplish, and bleeding. The mucus discharged is mixed 
with blood, and sometimes considerable haemorrhage occurs in conse- 
quence of the yielding of a vessel. The colon above is impacted with 
hardened faeces, and its outlines can be distinctly traced by palpation. 
In the severe form of proctitis there is usually some constitutional dis- 
turbance — some feverishness, headache, and general muscular soreness. 
The neighboring organs sympathize with the rectum. In the female, 
the menstrual flow may occur, and, in both male and female, strangury 
comes on, and with the straining at stool there is simultaneous straining 
at the passage of urine. The long-continued distention of the colon 
induces an irritation of the mucous membrane ; a catarrhal process is 
set up for the expulsion of the accumulated faeces, but the muscular 
layer, over-distended, becomes paretic and is incapable of any energetic 
action ; the inflammation extends and ultimately the peritoneum be- 
comes involved. The progress of these structural changes is mani- 
fested objectively by an increasing tenderness along the track of the 
descending colon, and finally by an extension of the inflammation to 
the adjacent connective tissue, the formation of a tumor, terminating 
in an abscess. In the cavity of the pelvis a similar process may take 
place, the inflammation of the mucous membrane extending by con- 
tiguity to the layers of the bowel successively, and at length involving 
the neighboring connective tissue. The chronic form of proctitis pre- 
sents nearly the same features. There are usually accumulations of 
scybala in the sacculated periphery of the colon, but the bowels may 
be confined or relaxed. The relaxed stools contain a good deal of 
mucus, and are highly offensive by reason of the decompositions which 
have ensued in the descent along the colon, and the scybala are coated 
with mucus. Instead of ordinary mucus, the matter now discharged 
contains purulent elements — muco-pus — and ultimately becomes en- 



PROCTITIS. 



89 



tirely purulent in tlie rectum. Ulcerations ensue, sloughs separate, 
and hence the stools contain the debris. The nerves become somewhat 
accustomed to the irritation of their terminal filaments in the muoous 
membrane, and therefore the reflex incitement to tenesmus is much 
less. There are, therefore, less straining, less acute pain, but the stools 
are more unhealthy. 

Course, Duration, and Termination. — The mild form of catarrh of 
the rectum has a natural tendency to cure in from four to eight days. 
The bowels act freely, the colon is emptied, and the tenesmus ceases. 
In the more severe cases, although a spontaneous cure may result, yet 
there is great danger of peritonitis, or periproctitis and abscess. 
When the latter forms, it tends to discharge alongside the rectum, re- 
sulting in fistula usually, or into the vagina or neighboring organs, 
forming various kinds of fistulse. The duration of the severe form is 
determined largely by the character of the treatment. The chronic 
form is obstinate, and pursues a uniform course leading to extensive 
ulceration, sometimes perforation and peritonitis, or cicatrization and 
permanent encroachment on the lumen of the bowel. Thrombosis of 
the inferior ha^morrhoidal veins, with subsequent formation of hepatic 
abscess by deposit of emboli, is a not uncommon result. These 
changes are all promoted by the fermentations occurring in the rec- 
tum, the products of which are highly irritating and offensive. 

Diagnosis. — The symptoms of acute proctitis are so distinctive 
that the diagnosis is made by them. In women, irritation of the rec- 
tum and tenesmus are produced by retroversion, especially of the gravid 
uterus. A vaginal exploration may be necessary to determine the po- 
sition of the womb : if the symptoms persist after the malposition is 
rectified, then it may be justly assumed that disease exists in the rec- 
tum. In women, the eversion of the rectum through the sphincter 
ani is so readily performed that the nature of the case may be deter- 
mined by ocular inspection. Exploration of the rectum may be neces- 
sary to differentiate between ulcer of the rectum and chronic proctitis. 
Many of the symptoms may be due to haemorrhoids ; an examination 
should be instituted whenever doubt exists. The author has known of 
two instances in which fecal accumulation and catarrh of the rectum 
were mistaken for scirrhus, and an unfavorable prognosis given. 

Prognosis. — A favorable termination may be predicted in every 
case of acute proctitis, unless implication of the peritoneum, perfora- 
tion, or periproctitis has occurred. When peritonitis has arisen, the 
prognosis is extremely unfavorable if it is general, especially if from 
perforation, but is less gloomy when limited by adhesions. In the 
suppuration which then ensues, the resources of the organism are 
severely tried ; in suppuration from periproctitis low down, although 
the strength may be much reduced, a fatal result is very rare ; but in 
these cases the local condition may be a mere expression of a dyscrasia, 
as tuberculosis, and they are to be estimated accordingly. In chronic 



90 



DISEASES OF THE DIGESTIVE SYSTEM. 



proctitis the gravity of the case is increased by accidental and conse- 
quential complications. The existence of cirrhosis is unfavorable, as 
it keeps up a constant over-fullness of the inferior hseraorrhoidal veins. 
Obstructive cardiac and pulmonary diseases act in the same way, 
though not so directly. The more changed the mucous membrane is 
in structure, the more extensive and deep the ulcerations, and the 
greater the hypertrophy of the muscular layer, the more serious the 
case. A very important complication is thrombosis of a hsemorrhoidal 
vein, with detached emboli, and subsequent multiple abscess of the 
liver. When this condition of things exists, the gravity of the case 
is vastly increased. 

Treatment. — Unless impaction is complete, and the peritoneal lay- 
er of the bowel implicated, the first duty to be done is to empty the 
colon of its retained faeces. It is a most serious mistake in treating 
acute catarrh of the rectum (dysentery), and one frequently made, to 
employ astringents and anodynes with a view to quiet the straining at 
stool. When the bowels are freely evacuated, little remains to be 
done in the ordinary cases. As already indicated, under similar con- 
ditions, there is no laxative so safe and efficient as Epsom salts. It 
should be given in solution with dilute sulphuric acid — 3 ij of sul- 
jDhate of magnesia and xx of dilute sulphuric acid in two ounces 
of water every two hours until the bowel is emptied. The straining 
at stool and the pain may be then promptly arrested by the hypoder- 
matic injection of morphia, or by enemata of tincture of opium in 
starch-mixture, or by opium in some form by the stomach. In the 
severe cases, the action of Epsom salts may be aided by irrigation of 
the bowel. A considerable quantity of warm water should be slowly 
injected, and retained as long as possible to soften the hardened faeces, 
and successive injections should be practiced at short intervals. These 
lavements are useful in allaying the excessive irritability of the mu- 
cous membrane. Other salines may be used, but none are so effective 
as the Epsom for this particular purpose. Enemata of emollients may 
be used instead of hot water — for example, infusion of flaxseed, of 
elm, of camomile, etc. — but they are really less efficient, because they 
are less solvent of the faeces. Various purgatives, notably castor-oil, 
have been used to dislodge the impacted faeces, but they do not estab- 
lish an outward diffusion to diminish congestion of the mucous mem- 
brane, which is the important action of the salines. In the severe 
form of proctitis, in robust subjects, and even in the weakly, leeches 
should be carefully applied around the margin of the anus. If there 
be much tenderness, an ice-bag should be applied over the descending 
colon, or warm fomentations, as already advised, for corresponding 
states. In chronic catarrh of the rectum, the diseased membrane can 
be reached directly, and the treatment should, therefore, be largely 
topical. Solutions of tannin (3 j — § iv), of fluid extracts of hydrastis 
and rhatany, and of other vegetable astringents, are effective local 



CROUPOUS OR MEMBRANOUS ENTERITIS. 



91 



applications if there are no solutions of continuity, but, if ulcerations 
exist, the most efficient topical application is nitrate-of -silver solution — 
four grains to a scruple, to an ounce of water. This should be injected 
through a tube carried up to the sigmoid flexure. Next to silver nitrate 
is the sulphate of copper, but this must be used very cautiously. It is 
important in these cases to maintain a soluble state of the bowels. 
When constipation occurs, the congestion of the mucous membrane is 
increased, and vice versa. Hardened faeces irritate in passing the in- 
flamed membrane. As fermentation, producing most unhealthy prod- 
ucts, takes place in the rectum, morning and evening enemata of hot 
water should be regularly used. They give great comfort, and con- 
tribute materially to the cure. The wasting caused by chronic catarrh 
of the rectum demands the use of the most nutritious food. Cod-liver 
oil is highly serviceable as food and medicine. If the digestion is fee- 
ble, it should be aided by the mineral acids and pepsin, and by nux 
vomica. Although medicines by the stomach occupy an inferior posi- 
tion in the treatment of this malady, excellent results are obtained from 
the use of minute doses of corrosive sublimate (one fortieth grain ter 
in die), of arsenic (two drops of Fowler's solution ter in die), or of 
sulphate of copper (one sixteenth grain ter in die) ; and when there is 
much mucus produced, cubeb, eucalyptus, and hydrastis act favorably. 

CROUPOUS OR MEMBRANOUS ENTERITIS. 

Definition. — By this term is meant an inflammation, subacute or 
chronic, occurring periodically, and characterized by the formation 
and discharge of membranous shreds or casts. 

Causes. — This is a disease of adult life chiefly ; it is rare in child- 
hood, and does not appear after forty-five. The female sex is more 
liable than the male ; and nervous, hysterical, and hypochondriacal 
subjects are more subject to it than are other types. A peculiar state 
of the nervous system seems necessary to its production. Membra- 
nous enteritis occurs by extension of the diphtheritic process down- 
ward, and false membrane also forms in infective dysentery, but the 
disease under consideration is a distinct affection. It has been attrib- 
uted to the ordinary causes of catarrh of the intestines — especially to 
irritants, as drastic purgatives, coarse food, etc.— but such agencies can 
act only as exciting causes. 

Pathological Anatomy. — Besides the exudation of diphtheria and 
of infective dysentery, deposits of a white or grayish-white color, 
flaky or membranous, and firmly adherent, have been found on the 
mucous membrane of the ilium and colon. Occurring first in iso- 
lated patches, the membrane extends laterally along the mucous folds 
in the small intestine, and in the colon upon the ileo-cgecal valve 
and the folds of the sigmoid flexure (Leube). In other cases (Sir 
James Simpson) papular and white vesicular eruptions have been 



92 



DISEASES OF THE DIGESTIVE SYSTEM. 



found, but no flaky membrane or casts adherent to the mucous mem- 
brane. 

The membrane as passed has been carefully examined microscopi- 
cally and chemically by Da Costa,* whose memoir on this disease is 
by far the most important contribution which has been made to our 
knowledge of the subject. The shreds, casts, or membranous masses, 
consist of " a transparent, amorphous, basement substance, here and 
there indistinctly fibrillated, and having imbedded in it granules, free 
nuclei, and small, shriveled, irregular, and rather granular cells." 
Chemically, this material has the same reactions as mucus (Da Costa) 
— a fact which might a priori be expected, since this false membrane 
is nothing more than solidified mucus, the granules, free nuclei, and 
granular cells found in it being remains of mucus-cells which escaped 
entire destruction in the process of solidification. The mucous mem- 
brane of the rectum, in a case examined by Da Costa, was intensely 
injected. 

Symptoms. — The attacks are announced by a feeling of soreness 
and distention of the abdomen, and constipation. There is no fever, 
the hands and feet are cold and moist, and the general condition that 
of depression, in which the mind participates. Before, indeed, any 
local manifestations of disease, there are apt to be attacks of hysteria 
or hypochondriasis, and the subjects of this disease are nervous, excit- 
able, neuralgic. The pains have the colicky character, are felt around 
the umbilicus chiefly, and are exceedingly severe and depressing. 
They continue for a half hour, for an hour or two, and even longer, 
and, after a variable interval of some hours' duration, occur again. 
Thus, during the twenty-four hours, there may be six or more par- 
oxysms. The distress does not cease with the subsidence of the acute 
pain : a feeling of rawness ard soreness remains, and the abdomen is 
so sensitive to pressure that peritonitis may be suspected. Very con- 
siderable tenesmus exists, and more or less mucus, with or without 
blood, is passed, as in acute catarrh of the rectum. There may be 
several loose evacuations a day, or the bowels may be confined. 
After several days of suffering, there will be discharged, with great 
pain and tenesmus, shreds of membrane or cylindrical casts of the 
bowel. Great relief is experienced. The soreness subsides, the dis- 
tention lessens at once, and the tenderness diminishes. The patient is 
left in a condition of great debility and much emaciated, for during 
the paroxysm there is complete anorexia, and sometimes vomiting, so 
that but little food is taken. The paroxysms are rarely single ; in a 
week or two, or after several months, there is a renewal of the same 
experiences. In one of the author's cases there were paroxysms sev- 
eral times a week for three weeks, the patient passing an almost in- 



"The American Journal of the Medical Sciences," October, IS*?!, p. 321, ct seg. 



CROTJPOUS OR MEMBRANOUS ENTERITIS. 



93 



credible quantity of false membrane. The same voman, in an attack 
three years before, had a succession of paroxysms for six weeks, and 
was so reduced that her life was despaired of. During the interval of 
three years there were no paroxysms, but she suffered from constant 
troubles of digestion. In the cases related by Da Costa, disorders of 
digestion continued and were very persistent. Acidity, ulcers of 
the mouth, red, tender, and coated tongue, were marked features. 
Disorders of the nervous system, also, were very pronounced. Hys- 
teria, hypochondriasis, headache, impaired memory, and defects 
of the special senses, are mentioned by Da Costa in the first rank 
as symptoms. In women, too, the menstruation was deranged, 
and various diseases of the sexual system were present. In one 
of the author's cases membranous dysmenorrhcea had existed for 
some years. As regards the intestinal symptoms, including the pas- 
sage of pseudo-membrane, variations from the description above 
given have been noted. The pain may continue during the interval 
between the paroxysms, although it is much less severe, and the 
membrane may be present in all the discharges occurring during 
months or years. 

Course, Duration, and Termination. — The course of membranous 
enteritis is irregular, and the duration indefinite. It may occur in 
paroxysms of a very acute character in quick succession, lasting two 
or three weeks or more, and followed by an interval of comparative 
health, to be succeeded after months or years by the same succession 
of symptoms. Or the cases may be less acute, and continue for 
months or even years. 

Diagnosis. — The distinction is to be made between membranous 
enteritis, dysentery, and tape-worm. The passage of shreds and casts 
of false membrane separates this malady from dysentery, unless there 
occurs separation or desquamation of the epithelium in the latter, 
when the aid of the microscope must be invoked. The smallest shreds 
of false membrane may be confounded with the strobila of a tape- 
worm colony, but, as the latter has a perfectly well-defined structure, 
and has the power of independent movement for a short time, only 
ignorance could possibly hesitate. 

Treatment. — The suffering which attends this malady requires re- 
lief, and the preparations of opium must be used. The most effective 
anodyne treatment is the hypodermatic injection of morphine. Kext 
to this are enemata of starch and laudanum. Xo specific treatment 
has been proposed, and only symptoms are to be prescribed for. In 
the author's experience, minute doses of corrosive sublimate, of cop- 
per sulphate, and of arsenic persistently used, are the most effective 
remedies for the more chronic cases ; for the acute, an emulsion of 
almond-oil, or castor-oil and turpentine when there is constipation. 
The author has had good results from tincture of nux vomica and 
tincture of physostigma, fifteen to twenty drops of each ter in die, for 



94 



DISEASES OF THE DIGESTIVE SYSTEM. 



the subacute and chronic cases, and the persistent use of hydrastis, 
eucalyptus, cubeb (fluid extracts), and other remedies acting similarly, 
is strongly advised. 

DYSENTERY. 

Definition.- — In common language dysentery is known as "flux" ; 
sometimes as " bloody flux " ; in technical, as ulcerative colitis. It is 
a disease characterized by tormina, tenesmus, mucus, and mucus-and- 
blood stools, burning pain, with more or less constitutional disturb- 
ance. It occurs in the sporadic, endemic, or epidemic form, and in the 
latter seems to be propagated by a specific virus. 

Causes. — It occurs in both sexes and at all ages. Sudden arrest of 
perspiration by exposure to cold, and especially to cold and dampness 
combined, is one of the most common causes. Climatic influences are 
very important factors in its production. It is a disease of those parts 
of the year in which the change of temperature from night to day is 
greatest, as in the later summer and autumn, and in warm rather than 
in cold climates. It is especially prevalent in malarious regions, doubt- 
less because of the congestion of the portal circulation induced by 
paroxysms of ague. Agents, whether of food or medicine, producing 
irritation of the mucous membrane, may cause a dysenteric attack. Is 
there a specific virus? Although during an epidemic the mode of 
propagation would indicate the existence of a specific infective mate- 
rial—a microbe — it is probable that this is nothing more than the dys- 
enteric discharges themselves acquiring increased virulence by the 
aggregation of numbers of sick under unfavorable hygienic conditions. 
The dysenteric excreta undergo certain fermentative changes, proba- 
bly, by which their infective property receives additional strength. 
They are admitted to the ground-water in the dried state ; finely di- 
vided they are distributed by the air, and in many ways, by the at- 
mosphere, food, and drink, they reach the intestinal canal of man, and 
there induce the characteristic disturbances and structural alterations 
of dysentery. On the other hand, the virus or infective material of 
epidemic dysentery may be a ptomaine, produced in great quantity 
when the materies raorhi reaches the intestinal canal. As an epi- 
demic, dysentery is a prevalent disease in armies, in jails, in tenement- 
houses — wherever, indeed, numbers of human beings are crowded to- 
gether under unfavorable hygienic conditions. Indeed, it seems almost 
certain that ileo-colitis and ulcerative colitis may be induced by the 
emanations from fecal accumulations and by the gaseous products of 
animal decomposition. Unlike contagious and other infective diseases, 
one attack of dysentery does not confer immunity; in fact, the ten- 
dency is increased with the number of attacks. 

Pathological Anatomy. — The structural alterations of dysentery 
may be comprehended in two groups, catarrhal or sero-purulent, and 
croupous or fibrinous. 



DY5EXTERY. 



95 



The first step in the series of changes occumng in the catarrhal 
form is an intense hypersemia, the mucous membrane being of a deep 
reddish color, with here and there blackish points. The redness is not 
universal, but at the summits of the mucous folds. This congestion is 
not limited to the mucous, but extends also to the submucous connec- 
tive tissue. As a result of this congestion there is over-production of 
mucus, which is found adherent, but not closely, to the membrane, and 
the follicles enlarge from an accumulation of their contents, while just 
around them is a girdle of enlarged vessels. The submucous tissue 
thickens greatly, and is infiltrated with serum, and this infiltration 
extends to the muscular layer. Softening of the mucous membrane now 
ensues ; it undergoes disintegration and gradual detachment, leaving 
still adherent here and there portions of membrane with ragged edges, 
and a coating of fibrinous pellicle, still in place. The follicles resist 
the destruction from softening longer than other portions of the mem- 
brane, but finally they slough out. The disintegration of the mucous 
membrane is the result of an enormous multiplication of pus-cells 
within the interstices ; the pressure is increased by the swollen vessels, 
and rapid necrosis (softening) ensues. Recovery readily takes place 
in the cases of catarrhal inflammation before the softening begins, and 
after softening if the destruction is not extensive. Repair is effected 
by cicatrices, which are much smoother, and, of course, devoid of 
gland-structures, and are therefore easily recognized. In the fibrinous 
or dijDhtheritic dysentery the alterations of structure are very differ- 
ent. The initial change, as in the catarrhal form, is an extensive 
hyper^emia, but, instead of being confined to the summits of the folds, 
(valvul[e conniventes of the small intestines, and the folds from con- 
traction of the muscular layer in the large) there is a universal deep, 
bluish-red congestion of the lower end of the ilium, and the whole of 
the colon. Extensive extravasations of blood infiltrate the whole tis- 
sue of the mucous membrane, but it is especially invaded and tranS' 
formed by a fibrinous exudation. The proper structure of the mucous 
membrane disappears entirely, except remains of the tubular glands, 
and it presents internally a reddish-white surface, variegated with ir- 
reo:ular blackish and reddish fio-ures. The result of these chano-es is 
to convert the membrane into a dense, parchment-like, and rather un- 
yielding tissue, composed largely of the deposited fibrin. If death do 
not take place when the alterations of the mucous membrane have 
reached this point, gangrene ensues. Although the ultimate changes 
in the two forms of dysentery are so distinct, yet in most cases the 
alterations found i^ost mortem are made up of both forms, the catarrhal 
and fibrinous. Those parts of the intestinal wall affected by the fibri- 
nous inflammation are thicker and more prominent than those attacked 
by the catarrhal. Hence the surface is uneven, the fibrinous parts 
dark from the presence of extravasated blood, or reddish- white where 
the fibrin predominates. Local gangrene patches appear, in size from 



96 



DISEASES OF THE DIGESTIVE SYSTEM. 



a copper cent to a silver dollar ; the membrane disintegrates and is de- 
tached in considerable sloughs, leaving deep excavations which extend 
deeper by succeeding necrosis to the peritoneum. The purulent infil- 
tration in those parts, the seat of catarrhal inflammation, also leads to 
extensive destruction of the submucous layer and large excavations 
beneath the mucous membrane, which is either detached as a whole, 
or in turn yields to necrosis. These more superficial catarrhal exca- 
vations contrast strongly with the dark-red or blackish sloughs of the 
fibrinous. 

The extent to which the intestine is involved varies greatly. The 
rectum, the crecum, or the sigmoid flexure, may be alone involved ; 
the whole of the large intestine, the disease beginning below and ex- 
tending upward, may be invaded. Repair is possible only when a 
small extent of the mucous membrane has been destroyed by gangrene. 
When the morbid process is arrested, the sloughs separate, granula- 
tions spring up, and the excavations are closed by cicatrices, which by 
subsequent contraction may seriously encroach on the lumen of the 
bowel. The structural alterations are not limited to the mucous, sub- 
mucous and muscular layers. When the ulcers reach the peritoneum, 
this membrane becomes cloudy, then intensely injected, and fibrinous 
exudation forms and adhesions are contracted to neighboring surfaces. 
When perforation ensues, a limiting inflammation may cut off the in- 
jured parts from the general cavity, and form a purulent collection, 
or general peritonitis may ensue if the shock does not terminate the 
history of the case. 

The mesenteric glands are enlarged, hypersemic, and softened, and 
often are broken down into abscesses. The liver is very commonly the 
seat of numerous small abscesses, from embolic obstruction of the 
radicles of the portal vein. The lungs present in their dependent 
parts the changes of hypostasis. The heart is small, flabby, and its 
muscular tissue more or less fatty. 

Symptoms. — In the epidemic form, dysentery may begin suddenly, 
without any preliminary symptoms, and with great violence, but in 
the endemic and sporadic form, and in the milder cases during epi- 
demics, there is usually a prodromic or preliminary stage. There is 
more or less catarrh of the intestines, diarrhoea, chilliness followed by 
feverishness, toward evening especially, and that state of general dis- 
comfort known as malaise general. 

In the mildest cases of dysentery there is no fever, but when the 
symptoms are at all pronounced there is fever of a remittent type, 
the exacerbation occurring toward evening. The type of the fever is, 
of course, determined by the extent of the local lesions. 

When actual dysenteric symptoms come on, which happens in two 
or three days after the first of the prodromic period, very decided ab- 
dominal pain is felt along the course of the descending colon and about 
the sigmoid flexure, and is increased by pressure at these points. Thcce 



DYSENTERY. 



97 



abdominal pains, felt also somewhat about the umbilicus, are de- 
scribed by the term tormina — " colicky pains." There is pain of a 
burning character in the rectum, but especially a sense of the presence 
of a foreign body, with the desire to strain for its expulsion. The 
patient resorts again and again to the close-stool, and makes strong 
efforts at expulsion, but instead of any faeces being discharged he only 
brings away some jelly-like matter — mucus — either alone or tinged 
with blood, and occasionally a hard ball of faeces {scybala), but without 
any relief. The feeling of bearing down {tenesmus) and the burning 
pain felt in the rectum and through the hips continue as before, so that 
he finds it impossible to quit the stool, or returns every few minutes, 
and each time he sinks back to bed exhausted and unrelieved. At the 
beginning, before the characteristic dysenteric stools appear, there are 
loose fecal evacuations containing mucus, voided with great pain. Pres- 
ently, however, faeces are no longer present in the evacuations ; they 
consist of a grayish, tough, transparent mucus in pellets or small masses, 
containing here and there whitish granules, w^hich have been likened to 
grains of sago. On the second or third day, blood appears in the stools, 
and the debris of epithelium are mixed with the mucus. In the mildest 
cases, the course of the disease is ended wdth these manifestations. 
These do not differ from the mildest cases seen during the existence of 
an epidemic ; on the other hand, the most formidable, the fulminant 
cases, may occur sporadically. In the more pronounced examples, after 
three or four days, severer sj^mptoms make their appearance — the 
amount of blood discharged increases ; not only the debris of epithe- 
lium, but the pellicular neo-membrane (an exudation) and necrosed 
parts of the mucous membrane are now to be detected in the stools. 
The stools have no longer any fecal odor, but are very fetid from the 
presence of gangrenous portions of mucous membrane. The grayish, 
transparent mucus gives place to a puriform fluid, and there is not 
only considerable admixture of blood, but a good many clots of pure 
blood are also discharged, and indeed a real haemorrhage may occur. 
A stool may consist of a bloody, purulent fluid and scybala, and the 
next be composed largely of an extremely fetid, brownish fluid con- 
taining bits of neo-membrane and masses, often of considerable size, 
of decomposing gangrenous sloughs of the mucous membrane. Some- 
times a cast of a part of the bowel, consisting of the mucous membrane 
in a complete cylinder, all of its parts distinct enough for recognition, 
will be discharged. These ought not to be confounded w^itli the infi- 
nitely rarer accident of a slough of the bowel itself, several feet in 
length, cast off by intussusception. As has already been pointed out, 
in the catarrhal form of dysentery, deep-seated suppuration in the 
submucous layer sometimes extends widely, and the mucous membrane 
sloughs off before it has had time to become gangrenous. During the 
tormina nausea is often felt, and vomiting occasionally occurs. In the 
9 



98 



DISEASES OF THE DIGESTIVE SYSTEM. 



severe cases, vomiting is constantly present and adds materially to the 
gravity. The vomited matters consist of articles of food and drink, of 
gastric mucus, and ultimately of biliary matters from the gall-bladder. 
The bladder in severe cases is also aifected by tenesmus. The urine is 
scanty, high-colored, and very acid, and therefore irritating, and so 
sensitive does the bladder become that a few drops of urine present in 
it excite the tenesmus, and in the straining both the bladder and the 
rectum are simultaneously affected. The frequency of the stools repre- 
sents pretty nearly the gravity of the case. In the mild cases there may 
be ten to twenty daily ; in the severe cases forty or fifty, and in the 
fulminant they may reach a hundred or more. Lessened frequency 
is a good indication when the character is improved. The amount 
discharged is small unless hemorrhage occurs. Artificial distinctions 
based on the character of the stools have been made, but these have 
no practical importance. It must be obvious that a disease affecting 
so large a part of the intestinal mucous membrane, and of so formidable 
a character in itself, must quickly impair the bodily forces. Even in 
the mild cases considerable emaciation occurs and the return to health 
is slow. In the severe cases, systemic infection results from the prod- 
ucts of decomposition and from the gangrene, and they wear the 
aspect peculiar to this state. The weakness early reaches the point 
that the patient is unable to leave the bed ; the evacuations pass with- 
out his control ; the anus and neighboring parts become excoriated 
and bed-sores quickly form. The face wears an anxious expression and 
is pinched ; the skin is dry, harsh, and wrinkled ; the pulse small, quick, 
and feeble, \yith the most painstaking care the person and bedding 
of the patient will be fouled with th-e discharges and emit a horribly 
fetid odor. From this condition of depression the case passes into the 
stage of collapse, when the pulse ceases at the wrist and the heart beats 
very feebly, an obstinate hiccough comes on, the skin is covered with 
a cold sweat, the hands and feet become cold and livid ; the face is 
shrunken, the eyes deeply sunk, the voice husky. In this condition 
the patient usually betrays a singular apathy, although the mind re- 
mains clear until the failure of oxygenation of the blood causes carbonic- 
acid poisoning and stupor. The state of collapse may not come on iu 
this gradual way, but the patient pass suddenly into it, by reason of per- 
foration of the bowel and the resulting shock followed by peritonitis. 
Death does not necessarily ensue immediately after the symptoms of 
collapse have been fully developed. The patient may remain in this 
low state for several days, now presenting delusive appearances of 
improvement, now declining. Various complications may arise dur- 
ing the course of dysentery. Thrombosis of the intestinal veins, or 
a form of phlebitis, or the absorption and deposition of some unknown 
morbific material, may excite inflammation and abscess of the liver. 
This is a common accident in tropical regions and in the interior 



DYSENTERY. 



99 



of the American Continent. Hepatic abscess is, however, more fre- 
quently due to the milder than the severer forms of dysentery, because 
of the destruction by gangrene and the rupture of vascular communi- 
cation, which takes place in the latter. It follows disease of the rectum 
much more commonly than of the colon or caecum, because of the 
greater abundance of large vessels in the latter and the comparative 
sluggishness of the blood-current. Besides abscess of the liver, puru- 
lent collections are sometimes found, as the author has seen, in the 
lymphatics at the root of the lungs and elsewhere. Peritonitis is 
a usual complication, not due necessarily to perforation, but to the ex- 
tension of the ulceration to the peritoneum. Increased tenderness of 
the abdomen and an exacerbation of the systemic symptoms are evi- 
dences of the onset of this complication. 

Course, Duration, and Termination.— In the mild cases the disease 
usually begins with diarrhoea ; tormina and tenesmus are felt about 
the second day, when also mucus appears mixed with faeces. About 
the third day the more characteristic stools are seen, and the disease 
has attained its height on the fifth and sixth days, when improvement 
begins, and convalescence is established about the eighth day. The 
signs of improvement are, a diminution in the number and frequency 
of the stools, the reappearance of faeces, and the disappearance first of 
the blodd and next of the mucus. In the more severe cases the dura- 
tion is more protracted. The maximum in the intensity of the symp- 
toms continues for several days ; the state of adynamia is more serious 
and prolonged, and the return toward health may be by almost insen- 
sible gradations, lasting several days. The prodromic period in such 
cases will be about three days, the fully developed period will range 
from four days to a week, and the period of gradual improvement will 
last about the same time, so that the whole duration of such a case will 
be about three weeks, while the convalescence will require a month 
for full restoration to health. The termination may be in partial 
recovery, or in chronic dysentery. When this is the case, the more 
severe symptoms subside, the stools improve in character, but they 
never become entirely healthy, and the general condition is more 
favorable. Now fecal stools, with only a little mucus and blood, are 
passed, but these may be succeeded by evacuations entirely of pus and 
blood. With this varying fortune the case may proceed for months, 
even years, the patient in a feeble state, emaciated, and yet able to 
keep out of bed, or so reduced as to be unable to sit up except for a 
little while every day. The prolonged suppuration in these cases in- 
duces amyloid degeneration of the liver, spleen, and kidneys, the ulti- 
mate result being albuminuria and anasarca. 

Another mode of partial recovery is narrowing, contraction, and 
deformation of the bowels, the effect of which is to impair assimilation 
and nutrition, so that after a period of improvement a progressive loss 



100 



DISEASES OF THE DIGESTIVE SYSTEM. 



of flesh and strength is observed, and ultimately death occurs by ex- 
haustion. 

Prognosis. — Opinions must be expressed with caution in the early 
stages of dysentery, for it is not then possible to estimate correctly the 
extent of the inflammation, nor its form. A favorable prognosis can 
be given in those cases which continue mild, and even in severe cases, 
if the signs of collapse are absent. Whenever the symptoms begin 
with great violence (fulminant form) a guarded prognosis is judicious. 
If the symptoms of collapse are persistent, especially if gangrenous 
sloughs appear in the stools, an unfavorable opinion must be given. 
In severe and protracted cases that are apparently improving, the 
probability of a partial recovery should not be lost sight of. 

Diagnosis. — The symptoms are so characteristic that a differentia- 
tion is rarely required, except as between simple and acute catarrh of the 
rectum (proctitis) and dysentery proper. The dysenteric symptoms in 
proctitis are much less severe ; the discharges consist of mucus and 
muco-pus, sometimes intermixed with blood, but never the foul dis- 
charges of dysentery, the shreds of false membrane, the gangrenous 
sloughs, etc., which constitute so characteristic an evacuation. In 
croupous enteritis, which is as rare as dysentery is common, there are 
discharges of shreds of pseudo-membrane with tormina and tenesmus, 
but the attacks are paroxysmal, the evacuations continue the same, and 
the subsequent history is widely different from that of dysentery. 

Treatment. — As in this disease the nutrition of the body suffers 
severely, the right use of aliment is important from the beginning. 
If the stomach is irritable, milk, with one fourth lime-water, is the best 
food. If there is but little nausea, and especially if the digestion re- 
mains good, the patient can take milk, eggs, beef-juice, ice-cream, 
boiled custard, oyster-soups, mutton, chicken, and beef broth, and simi- 
lar articles, but solids and aliments generally leaving much residuum, 
and especially coarse articles, are highly objectionable, because they in- 
crease by friction the irritation of the inflamed membrane. Where there 
is much depression of the powers of life, egg-nogg (milk, egg, and bran- 
dy) may be freely given, and champagne be used to allay vomiting. 

Of medicinal measures, the treatment by saline laxatives is of the 
highest importance. Bretonneau, preceptor, and Trousseau, pupil, 
strongly urged the sulphates, and the author is convinced that the sul- 
phate of magnesia in solution with dilute sulphuric acid is entitled to 
the first place as a remedy. It must be given in laxative doses, and at 
the right time — that is, before the mucous membrane has begun the 
process of disintegration. It serves a triple purpose : it empties the 
canal of retained faeces ; it lessens hypergemia by setting up an out- 
ward diffusion ; its after-effect is astringent and sedative. Next to 
the sulphate of magnesia, and by many given the first place, is ipecac. 
The experience with this remedy, ancient and modern, is now so great 
that the limit of its curative power is well and accurately defined. It 



DYSENTERY, 



101 



is applicable to tbe first stage of dysentery, before the mucous mem- 
brane is stripped off. It must be given, according to recent Indian 
experiences, in which the author in the main concurs, in scruple to 
drachm doses, every four to six hours. The effects to be derived from 
it are these : The first doses empty the stomach thoroughly, then a 
tolerance is established, and the considerable doses prescribed are car- 
ried quietly by the stomach, but act on the intestinal canal, producing 
copious bilious evacuations, so characteristic as to be called " ipecac- 
stools " ; after the purgative action ceases a calmative and astringent 
action continues. The utility of ipecacuanha ceases with the produc- 
tion of the characteristic stools, and very decided amelioration in the 
remediable cases usually follows. There is one form of dysentery, 
above all others, in which the ipecac-treatment is signally beneficial — 
the puerperal. The author has witnessed some remarkable cures in 
cases of puerperal dysentery, a disease which is well known to be 
very dangerous to life. As regards the dose, the large quantity of a 
drachm prescribed by our Indian colleagues seems unnecessary in our 
temperate climate. It will usually be necessary to give twenty grains 
at a dose. It is best administered in milk, and is better borne if some 
aromatic powder is added to it. The next remedy in point of effi- 
ciency for the treatment of the first stage of dysentery is castor-oil, 
administered in purgative doses, for the purpose of ridding the canal 
of acrid and fermenting materials, and of retained faeces, and to secure 
the after-quietude which succeeds to the action of a purgative. After 
using one of the agents of the cathartic group as above directed, what 
remedies are most appropriate for the treatment of that condition in 
which either purulent or fibrinous infiltration, or both, is taking place ? 
Under these circumstances an emulsion of oil (almond-oil) and tur- 
pentine is very serviceable, and combined with opium, if the pain be 
very severe. When destruction of the mucous membrane is begin- 
ning, the most effective remedies are corrosive sublimate, sulphate of 
copper, sulphate and oxide of zinc, acetate of lead, bismuth, arsenic, 
etc. Of this formidable list, sulphate of copper and arsenic are most 
effective. They ought to be combined with opium. The author has 
had excellent results from the use of Fowler's solution, one drop, and 
deodorized tincture of opium, five to twenty drops every three hours. 
Sulphate of copper must be given in small doses (one twentieth of a 
grain) every three hours, with morphine (one eighth to one twelfth of a 
grain). Bismuth in large dose {3 j — 3 ij) every four hours is some- 
times beneficial, especially if administered with carbolic acid. When 
there is much fetor and sloughs are threatening, good effects are ob- 
tained from naphthaline (two grains every three or four hours), carbolic 
acid, thymol, etc. Numerous vegetable astringents, owing their thera- 
peutical power to the tannic acid which they contain, have been much 
employed, with more or less advantage, but they are not equal to the 
mineral astringents. Applications to the rectum and colon are un- 



102 



DISEASES OF THE DIGESTIVE SYSTEM. 



questionably useful. By the method of irrigation the whole of the 
colon may be safely reached. Excellent results are obtained by wash- 
ing out the bowels with warm water (100° to 105° Fahr.). The patient 
is placed on his right side, the thighs well flexed on the pelvis, the hips 
elevated and brought to the margin of the bed, the chest and head on 
a lower level. The anal tube is inserted two or three inches, and the 
reservoir is placed at a sufficient height to insure the passage of the 
water. Various demulcent applications may also be made in this way. 
Very great relief is afforded by the injections of starch and laudanum 
after an evacuation, or especially after irrigation and washing out the 
bowels. Much emphasis should be ]3ut on the employment of nitrate 
of silver enemata. They possess a high degree of utility if efficiently 
administered. A tube which is not acted on by the silver salt should be 
passed carefully up to the sigmoid flexure, and about eight ounces of 
a strong solution of silver nitrate — 3 j to the ounce) should be 
thrown up. The time for performing this is after sufficient quiet has 
been obtained by the hypodermatic injection of morphine. So rapidly 
is the insoluble chloride of silver formed that no ill results can follow 
the strongest solution employed for this purpose ; but, if there be any 
reason to apprehend mischief, a solution of common salt may be in- 
jected immediately after the silver. 

If the injections are, for any reason, inadmissible, suppositories of 
cacao-butter containing morphine, morphine and tannin, morphine, or 
opium and acetate of lead, etc., can be used instead. Lately injections 
and suppositories of fluid extract of ergot, and of ergotin, have been 
used, and apparently with good results. Ergotin has been given in- 
ternally, and, in some epidemics, with an apparent utility which the 
physiological effects probably warrant. It is difficult to understand 
how it can accomplish anything when in the catarrhal inflammation 
the mucous membrane is infiltrated with pus, and in the croupous with 
fibrin. After the use of the saline laxative, or the ipecac, the morbid 
process continuing, is there no means of securing that quietude of the 
intestine which will permit the mineral astringent to act on the diseased 
surface ? The author believes that we possess such an agent in the 
hypodermatic injection of morphine. He therefore urges, from the 
point of view of personal experience, this means of treatment. Besides 
giving the remedies an opportunity to act on the diseased surface, the 
morphine injections suspend that violent reflex peristalsis which does 
so much injury to the diseased mucous membrane. External applica- 
tions, if not curative, are grateful. The cold wet pack, the ice-bag, and 
other cold aj^plications, are sometimes preferred ; but generally warm 
— rather hot — applications afford more relief. The turpentine stupe 
is generally more useful than other warm applications. With the be- 
ginning of the symptoms of collapse, active stimulation may be neces- 
sary. The best form of stimulant is cognac brandy, as it is at the 



ULCERS OF THE INTESTINES. 



103 



same time astringent. Beef -juice and brandy, milk and brandy, and 
egg-nogg, are combinations of food and stimulant most generally use- 
ful. As already indicated, tbe strength must be supported from the 
outset by suitable nutriment. It is necessary to keep the person of the 
patient and the bedclothing clean. The discharges should be removed 
from the apartment as soon as passed, and should be thoroughly disin- 
fected before going into the common receptacle, A strong solution of 
sulphate of iron is a cheap and effective agent for this purpose. Some 
tincture of iodine exposed in a saucer is an excellent deodorizer for 
the apartment of the patient. 

ULCERS OF THE INTESTINES. 

Forms. — Ulcers of the intestinal canal exist in three forms : 
Ulcers from mechanical irritation. 
Ulcers from thrombosis or embolism. 
Ulcers from tuberculous deposit. 

There are duodenal ulcers, caecal ulcers, and rectal ulcers, and an 
anatomical classification might, therefore, be adopted. It will be con- 
venient, in the description, to study these ulcers, according to their 
anatomical position, going from above downward.. 

The Nature, Symptoms, and Treatment of Ulcers of the Duodenum. 
—The first or transverse part of the duodenum is the almost exclusive 
seat of the ulcer. The pathological history of this ulcer is the same as 
the corresponding ulcer of the stomach. The great factor in its causa- 
tion is thrombosis, or embolic obstruction of a vessel. An admirable 
instance of this accident (the embolus in position, the ulcer forming) 
has been reported,* confirming clinically that which had previously 
been demonstrated by pathological experimentation. When the blood- 
supply has been cut off from a part of the mucous membrane, the 
digestive juice, no longer opposed by the alkaline stratum beneath, dis- 
solves or digests the membrane, and an ulcer is formed. At first it is 
a round, smooth, sharply defined ulcer, but the inflammation which is 
lighted up cuts off the action of the gastric juice from the adjacent 
healthy tissues, by a deposit of new material of a granulation-tissue 
structure, and especially protects the bottom of the excavation ; other- 
wise perforation would quickly ensue in most cases. As the layers of 
the duodenum are invaded, not all at once, but successively, and as the 
distribution of the vessels is fan-shaped, it is obvious that the resulting 
ulcer must have shelving margins and a stratified appearance. The 
term " crater-like " aptly enough describes its characteristics. 

This description of the process by which duodenal ulcers are formed 
can be applicable to ulcers situated in the first part of the duodenum 

* Merkel, "Wiener Pressc," various numbers in 1866. 



101 



DISEASES OF THE DIGESTIVE SYSTEM. 



only, for, soon after the acid contents of the stomach reach the vertical 
part, they begin to have an alkaline reaction. It is in the lirst part 
that the ulcers are found, and they are sometimes partly in the stomach 
and partly in the duodenum. They are usually single, and occasionally 
multiple. The cause that gives origin to one may produce several (em- 
boli), so that it is not uncommon to find gastric and duodenal ulcers 
existing at the same time. As regards the relative frequency in the oc- 
currence of ulcers in the stomach and duodenum, respectively, they are 
found in thfe former organ thirty times more frequently than in the 
latter. The duodenal ulcer is found between thirty and forty years of 
age in a great majority of cases, and becomes very rare after sixty 
(Krauss).* As to sex, the preponderance is in favor of males, and is so 
extraordinary in proportion as fifty-eight to six. Accident in the collec- 
tion of cases had something to do with these figures. Besides the causes 
already mentioned, burns of the skin, especially of the chest and abdo- 
men, have induced ulceration of the duodenum. The burns must be of 
considerable extent to bring it about, siifficient to cause a reflex spasm 
of the vessels, thus permitting the gastric juice to act on the membrane. 
If the ulceration reaches the peritoneum adhesions may be contracted 
to neighboring organs, to the stomach, pancreas, gall-bladder, etc., and 
fistulous communications may be established ultimately between them. 
In the process of widening of the ulcer, a vessel may be opened and 
haemorrhage result, a very common symptom, occurring in one half of the 
cases. By perforation a local peritonitis may be set up, adhesions con- 
tracted, and a cavity containing sero-purulent fluid, shreds of tissue, etc., 
formed ; or the general cavity of the peritoneum may be entered and 
general peritonitis excited. AYhen an ulcer of the duodenum heals, 
the puckered cicatrix which results may induce remarkable changes. 
Contraction of the pyloric orifice and dilatation of the stomach will be 
results of the cicatrization of an ulcer situated at the entrance to the 
duodenum ; if lower down, the lumen of the bowel will be encroached 
on, and dilatation occur above the contraction. An ulcer may be so 
situated that the pancreatic and common duct of the liver will be ob- 
structed with the usual results of such obstruction. Ulcers of the duo- 
denum situated near the pyloric orifice will be accompanied by some of 
the symptoms of a gastric ulcer situated at or near the pylorus. Vom- 
iting is a pretty nearly constant symptom, coming on several hours after 
eating. Tenderness to pressure, and, when the ulceration approaches 
the peritoneal surface, rather exquisite tenderness, is felt in the posi- 
tion of the duodenum. Attacks of gastralgia, of enteralgia rather, and 
of a severe character, occur under the same circumstances as gastralgia 
in stomach-ulcer. The pain is distributed through the solar plexus 
and the hepatic plexus also, and is of a very depressing kind, the 



"Das perforircnde Geschwvir im Duodenum," Berlin, 1865, p. 24. 



ULCERS OF THE INTESTINES. 



105 



action of tlie heart becoming exceedingly feeble, the surface cold, etc. 
Jaundice may also be present. When this is the case, it would be im- 
possible to differentiate between ulcer of the duodenum and hepatic 
colic. Hsemorrhage may take place by emesis or by stool. In duode- 
nal ulcer it may, in consequence of the size of the vessel (the ascending 
vena cava, for example), be so large as to cause death immediately. 
The blood, unless in large amount, is much changed in character by the 
action of the intestinal juices, as has been pointed out. The diagnosis 
may be aided by a study of the haemorrhage, the part discharged by 
vomit having the characteristics of hjematemesis, that passed by stool 
presenting the appropriate changes. As regards treatment of ulcer of 
the duodenum, the plan proposed for gastric ulcer is applicable. (See 
Ulcer of the Stomach.) Ulcers similar in character to the duode- 
nal, but due to those alterations of the vessels which occur in amyloid 
degeneration, are occasionally found in other parts of the small intes- 
tines. The symptoms are obscure, and the diagnosis a mere matter of 
suspicion. The patient affected with an ulcer of this kind suffers with 
the changes wrought by amyloid degeneration, in the liver, kidney, 
spleen, and other organs. There are emaciation, pallor, oedema, diar- 
rhoea, etc., and there maybe soreness in a particular locality, and hem- 
orrhage, to indicate the nature of the intestinal disease, but obviously 
these are far from conclusive. The general condition is the point 
to which attention must be directed in these cases, yet no subject in 
therapeutics is more unsatisfactory than the amyloid disease. 

The Nature, Symptoms, and Treatment of Ulcers of the Caecum and 
Appendix Vermiformis. — Ulcers in these situations are usually of me- 
chanical origin, produced by the retention of hardened fteces, by the 
impaction of an intestinal or biliary calculus, or of another foreign 
body, such as a grape-seed, a cherry-seed, a pin, etc. These foreign bod- 
ies lodge more frequently in tho appendix vermiformis, but they may 
become impacted in a fold of the mucous membrane of the cfecum, espe- 
cially of the posterior wall, for this has a fixed position. The pressure 
of the foreign body excites inflammation, then softening, and finally 
perforation. The position of the ulcer affects the result enormously. 
If it perforate the posterior wall of the caecum, which is not covered 
by the peritoneum, the foreign body and other contents of the bowel 
escape into the loose connective tissue, where an inflammation ending 
in an abscess is set up. Then the history is that of fecal abscess. Oc- 
casionally a primary inflammation develops in the perico3cal connective 
tissue, an abscess forms, and a communication is established with the 
bowel. The author has had the opportunity to study a case of this 
kind which lasted two years, and at the autopsy a large pus-cavity in the 
iliac fossa behind the caecum communicated with the caecum by a con- 
siderable orifice. As the discharges of matter through the bowel had 
been paroxysmal, it is probable that the original opening was small. 



106 



DISEASES OF THE DIGESTIVE SYSTEM. 



If the foreign body is lodged in the appendix, inflammation is excited, 
and a perforating ulcer quickly formed. In some cases the whole ap- 
pendix is inflamed and converted into a diffluent mass. As the ulcer 
extends, the peritoneum is quickly reached. One of two results must 
then take place : either a local peritonitis wdth adhesions, limiting the 
mischief to that locality, or a sudden rupture into the general cavity 
of the peritoneum. If the process is slow, the peritoneum forms adhe- 
sions to the neighboring surfaces ; if rapid, the time is not sufiicient 
to accomplish this. When a limiting inflammation is thus developed, 
a cavity is formed, containing the matters which have escaped from 
the appendix, including any foreign body lodged there, fecal mat- 
ters, sloughs of the ulcerated surface, serum, and pus. In a short 
time the process of extrusion begins, the pus makes its way downward 
under Poupart's ligament, along the sheath of the femoral vessels, and 
points in the usual situation. In two thirds of the cases the purulent 
collection takes this direction ; in others it j^oints over the crest of the 
ilium, and posteriorly, in the lumbar region. Besides the ulcers of 
merely mechanical origin, the caecum is the seat of that form of ulcer 
known as the catarrhal — a fact which the author believes he was the 
first to demonstrate.* It is a fortunate circumstance that these catar- 
rhal ulcers, which have such a strong tendency to perforate the bowel, 
ere usually situated on the posterior wall ; doubtless in accordance 
with the now well-known law that those parts most exposed to injury 
in the performance of their functions are also most liable to disease. 
As may be seen by referring to the article on " Typhlitis," the symp- 
tomatology and treatment are the same as for ulcer, and indeed there 
is no well-marked distinction between them clinically, except it may 
be the vague symptoms of ulcer which precede the perforation for an 
indefinite period. The rectum is also the seat of ulceration of the 
catarrhal type. This has already been pointed out, and its symptoma- 
tology demonstrated, but more frequently ulcers of the rectum have a 
mechanical origin, are brought on by impacted faeces, the lodgment of 
a fish or other bone, of seeds, etc. Perforation ensues, an abscess is 
formed, which points alongside the rectum, in the perinaeum and else- 
Avhere, leaving troublesome fistulse. An ulcer of the rectum, healing, 
may produce narrowing and deformity of the bowel, seriously impair- 
ing its functions. But these ulcers of the rectum do not heal readily, 
for obvious reasons — the frequent muscular movements, the passage 
of rough matters over them, the constant presence of irritating solids, 
fluids, and gases, etc. 

As regards the treatment of ulcer of the rectum, there are two 
points — to keep the bowels soluble without frequent motions, and to 
make topical applications of the solid nitrate of silver. To this might 

* " On Typhlitis and Perityphlitis," "Amcr. Jour, of Med. Sci.," October, 1866, p. 351. 



ULCERS OF THE INTESTINES. 



107 



be added a third — stretching the sphincter. This can be done by a 
bivalve rectal speculum, working with a screw, when the parts are 
exposed for the applications to the surface of the ulcer. 

The Nature, Symptoms, and Treatment of Tuberculous Ulcers.— 
Ulcers of tubercular origin are not limited to any anatomical division 
of the intestine, but they occur most frequently in the lower end of the 
ileum, to which, indeed, they may be entirely confined. They may oc- 
cupy the whole extent of the mucous membrane from the stomach to 
the rectum ; they may be confined to the caecum, appendix, and colon. 

The deposit of miliary tubercle takes place in the follicles, which 
become crowded and obstructed, so that the cells undergo fatty degen- 
eration and atrophy. The miliary tubercle, in preparation for extru- 
sion, becomes caseous, softens, and carries with it the surrounding 
textures, thus forming an ulcer, which widens by the addition of new 
miliary tubercle, destined to undergo the same process of caseation, 
softening, and extrusion. The situation of the ulcers has reference 
chiefly to the distribution of the vessels, which is transversely, and on 
this anatomical fact has been based a means of distinguishing between 
tubercular and catarrhal ulcers. This is true only of the early stage 
of the tubercle deposit, and can no longer be depended on when, as 
subsequently happens, the formation of the ulcers takes place longitu- 
dinally also. By coalescence their form is greatly altered. The exten- 
■sion of tubercle-ulcers through the muscular layer of the bowel is very 
slow, and takes place chiefly along the lymphatics, ultimately reaching 
the peritoneum. Indeed, it is easy to trace with the naked eye the 
tubercle-masses crowding the lymph-vessels and the lymph-spaces 
adjacent. Deposits then cloud the peritoneum, a patchy exudation 
forms, and adhesions connect the neighboring serous surfaces, and so 
usual is this result that perforation by a tubercle-ulcer is rather un- 
common. Tuberculosis of the intestinal mucous membrane is a local 
manifestation of a general state ; hence, when these ulcers exist in the 
intestines, tubercular deposits will be found elsewhere. The most char- 
acteristic symptom of tubercular ulcerations is an obstinate diarrhoea, 
which resists every means of treatment, and is only palliated. The 
stools are usually yellowish, are very thin, and contain pus, small 
sloughs of the mucous membrane, etc., and are very fetid in odor. 
Colicky pains attend them, and tenesmus also, when, as is frequently 
the case, the rectum is involved. The stools contain also small, whit- 
ish lumps (sago-grains), masses of mucus extruded from those spaces 
which had contained the follicles. Clots of blood, an admixture of pus 
and blood, and of liquid faeces and blood, are also contained in the 
evacuations. The approach of the ulcers to the peritoneal surface is 
recognized by the increased pain, and the tenderness to pressure at vari- 
ous points. The general condition of the patient is highly significant. 
Emaciation proceeds rapidly. The evening temperature is high (103^ 



108 



DISEASES OF THE DIGESTIVE SYSTEM. 



-105° Falir.), and the fever is distinctly septicaemic in type. There is, 
at the same time, pulmonary mischief going on, as a rale, in these cases. 
Investigation will disclose the fact that an hereditary tendency exists. 
The treatment consists in the use of opium and astringents, vegetable 
and mineral. In the course of treatment of an ordinary case, all the 
resources of the materia medica in remedies of this kind will be ex- 
hausted. Under the heading of "Intestinal Catarrh" will be found 
some remarks on treatment equally applicable in this malady. 

CANCER OF THE INTESTINES. 

Forms and Site. — The three forms — scirrhus, medullary, and col- 
loid — which alfect the stomach, occur also in the intestines. As has 
been stated already in regard to cancer of the stomach, the origin of 
the neoplasm is epithelial, and the initial change (always, however, 
preceded by a pronounced local hyperasmia) is a proliferation of the 
cells of the follicles. The new cells extend downward and develop in 
greatest abundance in the submucous layer. The growth takes an 
annular direction, and in the contraction, which always results, the 
lumen of the bowel is encroached on and stenosis produced. As a 
rule, those parts of the bowel most active functionally, and in a situa- 
tion to be most readily injured in the performance of their functions, 
are most apt to be the seat of cancer ; the rectum, the caecum, and the 
flexures of the colon, are these parts. 

Cancer of the intestine is usually primary. It is a disease of ad- 
vanced life (after forty), although the soft variety, the medullary, may 
occur at any age. 

Symptoms. — There are three symptoms which have a high degree 
of significance : pain in a fixed situation ; a gradually developing ca- 
chexia ; the presence of a tumor. Until these symptoms appear, the 
diagnosis will be largely conjectural. The pain is at first a mere vague 
uneasiness ; gradually a sensation of soreness wdth some tenderness to 
pressure is developed, and finally there are two kinds of pain — a dull, 
heavy, tensive soreness, and acute, sharp, lightning-like pains. The 
pain may radiate somewhat from a center, but the most important 
characteristic of the cancer-pain is its fixed position. From the mo- 
ment pain is felt in a part the patient declines in strength and weight, 
and experiences a feeling of fatigue quite irrespective of any exertion. 
The complexion slowdy changes, until ultimately the faw^n-color be- 
comes well marked. The lips are then bluish white, the surface dry 
and scurfy, the skin wrinkled, the hair dry and dead-like. In cancer 
of the stomach and intestines the patients usually suffer from a profuse 
salivary flow without apparent cause. Sometimes just above the clavi- 
cle may be felt enlarged lymphatic glands. When the emaciation has 
removed the fat from the abdomen, a tumor can be felt. Although 



CANCER OF THE IXTESTINES. 



109 



cancer may form anywhere, it is at certain points where we may ex- 
pect to detect a tumor — the points of election already mentioned. In 
six cases of cancer of the intestinal canal, obseryed by the author with 
special reference to this account of the disease, there were two of the 
rectum, two of the ctecum, one at the sigmoid flexure, and one at the 
angle of the transyerse and descending colon. If the tumor is scirrhus, 
it is felt as a hard, nodular mass ; if encephaloid, an irregular growth, 
partly hard and partly elastic ; if colloid, a more diffused, less iiTegu- 
lar and softer mass, not well defined. Very great mistakes are made 
as to the size of a tumor, or indeed as to its presence, in cases of can- 
cer. As the stenosis increases, accumulations take place behind the 
point of narrowing, and then hard lumps of fieces may easily be con- 
founded with a nodular tumor. Subsequently the passage of the 
fieces will give a yery different impression, and the real tumor may be 
detected with difficulty or not at all. The atithor has observed this 
state of things in cancer of the ca3cum and of the flexures. The symp- 
tomatology of intestinal cancer varies with the site of the neoplasm. 
"When situated at the caictmi, pain is felt in the right iliac fossa ; there 
the tumor may be detected, and there the patient experiences the sen- 
sations due to the passage of gas and fieces through a narrowed orifice. 
Large accumulations of lumps of fieces and gas may occur at times, 
presenting the appearance of a large tumor, and may disappear spon- 
taneously in a day or two, or be made to disappear by gentle pressure 
and friction, when they pass through the orifice with a sensation of 
burning pain to the patient and with giu'gling quite audible to those 
around. The same phenomena occur at the flexures when cancer is 
developing. In the rectum there is severe, burning pain, of a most 
agonizing kind, whenever the bowels are moved, or indeed in sitting 
or standing long, and pains radiate through the hips, thighs, and 
testes. Usually tenesmus is present, and a constant desire to go to 
stool, when every attempt at defecation causes unendurable paiu, so 
that the patient, if possible, postpones the painful act as long as he 
can. The exploration of the rectum by the finger will furnish valuable 
information : hard nodules will be encountered, and masses may be 
detached from the ulcerating surface for microscopic examination. In 
one case the author found protrusion of the rectum and cancer-masses 
projecting thi'ough the anus, while the surroimding tissue (the rectal 
fossae) were covered over with enlarged veins and filled with nodes of 
stony hardness. The least attempt at exploration caused intolerable 
anguish, and the passage of faeces was accomplished by no less suffer- 
ing. The stools at first only indicate, if they are solid, that they were 
forced through a narrowed orifice ; they may be loose or constipated. 
In the progress of the cases, mucus, muco-pus, pus and blood, foul- 
smelling gangrenous masses, and parts of the neoplasm, successively 
appear and mark the stages in the growth of the cancer. ^Yith the 



110 



DISEASES OF THE DIGESTIVE SYSTEM. 



increasing stenosis the bowels are less completely emptied ; great accu- 
mulations finally take place ; and, ultimately, death may be brought 
about by the protracted constipation, ^yhen cancer is situated in the 
first part of the duodenum, it will finally be accompanied by jaundice 
and the symptoms of gastric cancer at the pylorus, so that it will be 
impossible to diagnosticate its position correctly — a failure of little 
moment. 

Rupture of the intestine may be caused by an extension of the 
growth to the peritoneum. 

Course, Duration, and Termination. — Cancer goes on steadily to a 
fatal termination, with now and then some delusive appearances of 
improvement. The course and duration vary somewhat with age, 
powers of resistance, and situation of the neoplasm. Cancer of the 
colon, unless it develops in a way to cause obstruction of the bowel at 
an early period, is not so quickly fatal as cancer of the caecum. Can- 
cer of the duodenum interferes so much with digestion and assimila- 
tion, and with the hepatic functions, that it causes death by exhaustion 
comparatively early. A severe haemorrhage from cancer in any sit- 
uation may determine a fatal result. The duration varies according 
to the mode of termination ; from one to three years may be regarded 
as the range. The termination may be by hgemorrhage, by perforation 
and peritonitis, by exhaustion, or by an intercurrent disease — as pneu- 
monia, pleuritis, pericarditis, etc. 

Diagnosis. — When there is no pain, but a feeling of uneasiness, no 
tumor has formed, no cachexia developed, a diagnosis will be impos- 
sible. From catarrh and ulcer of the intestines, cancer is to be differ- 
entiated by the age of the subject, the presence of a tumor, and the 
gradual appearance of a cachexia. The tumor of cancer may be con- 
founded with floating kidney, aneurism, fecal accumulations, and other 
growths. Floating kidney is a movable tumor, felt in different posi- 
tions, in which there may be occasional bowel attacks but no persistent 
disease, and there is no cachexia. Aneurism is a pulsating tumor, with 
an expansile movement, and the pulsation in one or both femorals is 
retarded by it and altered in character. An apparent pulsation is im- 
parted to a cancer of the colon by lying over the aorta ; but, if moved 
away by external palpation, or by a change in the position of the 
patient, the pulsation ceases, and at no time are the femorals affected. 
A cancer of the ciecum and of the sigmoid flexure may also come into 
relation to aneurism of the iliac arteries. The same rules apply as 
above given. 

A fecal tumor with colic may cause the merely local symptoms of 
cancer ; but the history of the case, it may be the age of the subject, 
will decide, and the cachexia will be wanting. The use of purgatives 
will settle the question. 

Prognosis. — No means are now known by which cancer can be 



IXTESTIXAL HJEMORRHAGE. 



Ill 



arrested in its course, mucTi less cured, so that the prognosis is entirely 
unfavorable. 

Treatment. — Although there are no curative measures to be under- 
taken, much can be done to alleviate the distresses of the unfortunate 
subjects. The most easily digested food, and the varieties vrhich can 
be utilized by the digestive organs without leaving any residuum, 
should be directed. The bowels should be kept in a soluble state to 
prevent accumulations, and to avoid friction of the hardened fseces on 
an irritable surface. To relieve the pain anodynes become necessary, 
but the physician must carefully guard their administration, owing to 
the enormous quantity which the patient will use if left to his own 
inclination. The author must repeat the statement which he has 
already made in regard to the utility of arsenic in cancer to relieve 
pain and retard the growth. 

INTESTINAL HEMORRHAGE. 

Causes, Sjnnptoms, and Diagnosis. — The subject of gastric haemor- 
rhage, which has been fully treated, is occupied with the same ques- 
tions, except the difference in position, as intestinal haemorrhage ; and 
therefore only a comprehensive but concise statement is necessary here. 

Haemorrhage from the intestines arises from all those morbid states 
which increase the blood-pressure in the portal system — as obstructive 
diseases of the heart and great vessels, of the lungs, and of the liver, 
especially ; from rupture of the vessels themselves occurring in the 
various kinds of ulceration of the mucous membranes, and from mor- 
bid states of the blood itself, as purpura, etc. The symptoms produced 
by an intestinal haemorrhage will vary with the immediate cause, with 
the amount of blood lost, and with the condition of the patient at the 
time. If considerable, the face becomes deadly pale, the eyes glassy ; 
there is a rushing and roaring in the ears ; the pulse becomes weak, or 
ceases at the '^'rist ; consciousness is lost, and a convulsive shudder 
passes through the muscular system, and death may ensue, without any 
escape of blood externally : or there may be mere faintness, and con- 
sciousness not lost ; a sudden and irresistible desire to have an evacu- 
ation of the bowels is felt, and blood in clots and partly fluid, or a 
blackish, semifluid, tarry mixture may be passed. When the haemor- 
rhage is from the descending colon, the blood discharged — if passed 
immediately — is unaffected by the intestinal juices, but, if it come from 
a point high up in the small intestines, it will appear as an homogeneous, 
tarry fluid, but may, of course, be mixed with faeces. When the blood 
escapes in small quantity, and slowly, there will not be any systemic 
evidences of the loss, except a slowly developing anosmia, and the ap- 
pearance of the blood in the stools will take place in the form already 
described. When the blood escapes from the rectum it may be passed 



112 



DISEASES OF THE DIGESTIVE SYSTEM. 



before, with, or after the faeces, which may be covered with blood, but 
are not mixed with it. The rectum offers great facility for the deter- 
mination of the source of the haemorrhage, and an examination will 
show whether the bleeding is from haemorrhoids or from an ulcerated 
surface. When an ulcer of the rectum exists, the passage of the faeces 
will cause some blood to flow, which will often be found on the top of 
the faeces, together with some pus. The importance of intestinal 
haemorrhage will depend, first, on the nature of the malady which is 
its cause ; and, second, on the amount of blood lost. If typhoid, or 
cancer, for example, the importance of the haemorrhage — unless itself 
suflicient to cause death — is merged completely in the importance of 
the malady associated with it. 

Treatment, — In the remedial management of intestinal haemorrhage, 
the same principles and methods are applicable as were recommended 
in the cognate disease — gastric haemorrhage. The most absolute quiet 
must be maintained, mustard-plasters and ice-bags applied to the abdo- 
men, ergotin injected subcutaneously, alum-whey drunk freely. If 
time is afforded, the usual iron styptics can be administered by the 
stomach, or if the source of the haemorrhage is low down they can be 
administered more efficiently by the method of irrigation or by ene- 
mata. The author has known of an instance of fatal haemorrhage 
induced by an injection of a solution of Monsel's salt, given to arrest 
a haemorrhage — caution is therefore necessary. An intestinal haemor- 
rhage is a mere symptom ; the treatment of it is necessarily a part of 
the disease with which it is associated. If it occur during the course 
of typhoid, very different management will be requisite from that 
necessary in purpura, or in cirrhosis, etc. Only general rules can 
therefore be indicated here. 

ENTERALGIA; NEURALGIA OF THE INTESTINES— COLIC. 

Definition. — The term enteralgia is applied to a neuralgia of the 
intestines, of a functional character, and is therefore a neurosis, and 
should be studied with the group of neuroses, but it is convenient to 
take it up at this point. 

Causes, Symptoms, and Diagnosis.^ — Except for the difference in 
site, the story of gastralgia might be repeated here. A more con- 
densed description than would otherwise be proper will now suffice. 

The causes of this affection can be comprehended in two groups : 
an irritable state of the nerves themselves ; irritation, by various 
objects, of the terminal filaments of the nerves (end-organs) in the 
mucous membrane of the intestinal canal. In the first group must be 
placed that condition of the nervous system existing in hysteria, hypo- 
chondriasis, and in the various cachexiae — paludal, plumbic, cupric, 
syphilitic, etc. ; and in the second, improper food, coarse and irritant 



ENTERALGIA. 



113 



articles, as husks of grain, seeds of fruits, etc. ; hardened faeces, im- 
pactions of faeces, fermentation and flatulent distention of the bowels ; 
cold, etc. 

An attack of colic may come on gradually with a feeling of uneasi- 
ness in the bowels, some nausea, eructations of gas, etc., or it may be- 
gin abruptly and develop full force at once. When it occurs by either 
mode, there is felt about the umbilicus a peculiarly severe and depress- 
ing pain, having the well-known griping quality. There are number- 
less gradations in the severity of the attacks, from a little griping pain 
felt for a few minutes, up to a seizure of such severity that the patient 
may appear as if collapsed. In any case of moderate severity, the suf- 
fering during the time the attack lasts is great — the patient groans or 
cries with anguish, the body is doubled up, and the lists are pressed 
deeply in the abdomen, or the abdomen is lain upon with the whole 
weight. Meanwhile the pulse is small and weak, the surface cool or cold, 
the face has an anxious and suffering expression, and is covered with a 
cold sweat. The abdomen may be hard and tympanitic or retracted, 
and occasionally tender, instead of pressure giving relief. The kid- 
neys secrete a large quantity of pale urine, and a frequent desire to 
micturate is usually felt. Vomiting generally occurs, and affords some 
relief, but an action of the bowels, which is always sought for, removes 
all the pain, at least for the time. Sometimes the attack terminates by 
a discharge of flatus, by eructation or by the bowels, and then relief is 
experienced. 

The duration of the attacks is variable — they last from a half hour 
to several hours, and a succession of attacks is not unusual, carry- 
ing the case on for several days. When the attacks are plumbic, 
the colic is known as dry, and obstinate constipation is a prominent 
symptom — the pain continuing until this is removed. The history of 
the individual, his occupation as a painter, and the behavior of the case 
itself, will indicate the nature of the attack. When it is paludal (mala- 
rious), the attacks will be distinctly periodical. If syphilitic, the pain 
will occur in the evening, and leave the patient unmolested during the 
day. The duration of those cases having their origin in a cachexia 
will depend on the treatment ; for, if the underlying morbid cause fail 
to be recognized, they may be prolonged indefinitely. 

Enteralgia may at once be distinguished from all inflammatory 
affections by the absence of fever, and of tenderness on pressure, and 
by the early termination of the seizure, leaving the status in quo. It 
is distinguished from gastralgia by the situation of the pain, and by 
the relief obtained by an escape of flatus and by an evacuation of the 
bowels, instead of by vomiting. It is distinguished from hepatic colic 
by the seat of the pain in the latter, by the tenderness over the gall- 
bladder, by the appearance of bile-pigment in the urine, and afterward 
of jaundice. It is distinguished from nephritic colic by the following 
10 



lU 



DISEASES OF THE DIGESTIVE SYSTEM. 



symptoms which indicate the latter : by the pain along the course of 
the ureter, by the pain in and retraction of the corresponding testicle, 
by the strangury and bloody urine, etc. 

The colic of gaseous accumulation is differentiated from th.e other 
forms by the fullness and tympanitic distention of the abdomen, and 
by the passage of gas in both directions. This is the colic of infants. 
The colic of fecal accumulation is recognized by the fullness of some 
particular part, and the occurrence of pain in the same locality, fre- 
quently the caecum and ascending colon, and at the sigmoid flexure. 
The colic of lead is associated with the lead-cachexia, with pallor and 
anaemia, with a blue line along the margin of the gum, with a slow 
pulse, with a retracted abdomen, etc. The enteralgia of chronic ma- 
larial poisoning is known by its prompt occurrence at a fixed time, as 
has been pointed out. 

The prognosis is favorable in genuine colic. 

Treatment. — The important point is to remove the cause which 
gives I'ise to the disturbance — if some irritant matters or fecal accu- 
mulation, an active purgative is indicated. The flatulent colic of 
infants is quickly and safely relieved by the bromide of potassium and 
oil of anise in an emulsion — five grains of the former and the eighth 
of a drop of the latter, every half hour until relieved. For the im- 
mediate relief there is no remedy comparable to the hypodermatic 
injection of morphia and atropia. By relaxing spasm, the injection 
favors the action of laxatives or purgatives. For the treatment of the 
colic of some cachexise, the appropriate remedies for the cachexia will 
be necessary : for example, quinia in intermittent colic, iodide of 
potassium in nocturnal colic, and alum in lead-colic. For the hysteri- 
cal colic, a combination of Hoffman's anodyne and fluid extract of 
valerian is effective. Enemata of asafoetida mixture may also be used. 
For chronic enteralgia of the bowel — an extremely obstinate affection 
— arsenic, probably, stands in the front rank. The neuralgiae are, 
however, considered more fully in another place, to which the reader 
is referred. 

CONSTIPATION. 

Definition. — As the term constipation is usually employed, it signi- 
fies a state of the intestinal canal in which the alvine evacuations too 
seldom occur. Obstruction of the bowels, whether due to impaction, 
concretions, tumors, or other causes, is treated of in a separate chap- 
ter. 

Causes. — Omitting from consideration all the conditions inducing 
obstruction, the causes of constipation are resolved into three groups : 
1. Those arising in deficient secretion ; 2. Those due to imperfect 
action of the muscular layer of the bowel ; 3. Those dependent on 
derangement of the nervous apparatus. When from any cause the 



CONSTIPATION. 



115 



intestinal juices, the secretions of the liver and pancreas, are reduced 
below the normal, a necessary stimulus to intestinal action is removed. 
As the peristaltic movements are derived from the contractility of the 
circular and longitudinal fibres of the bowel, it follows that, when their 
power of contraction is impaired, constipation results. In certain 
states of the nervous system^ the secretions of the mucous membrane 
and the contractile energy of the muscular fibres of the intestinal canal 
are both affected, with the result to render the intestines exceedingly 
torpid. Affections of the mucous membrane, disease of the liver and 
pancreas, the use of food leaving no residuum, over-action of the skin 
or kidneys, the state of anaemia or chlorosis, etc., lessen the proper 
action of the bowels by altering the character or reducing the amount 
of the proper secretions. The muscular contractility is impaired by a 
sedentary habit, by allowing the contents to accumulate, and dis- 
regarding the call to evacuate the canal, by the use of warm purga- 
tives, and by a depressed state of the nervous system. As the con- 
dition of the trophic and vaso-motor systems must have a direct effect 
on secretion, it follows that constipation may be produced by all 
causes depressing these functions, as despondency, protracted mental 
activity, certain metallic poisons, notably lead, and diseases of the 
spinal cord. 

Pathogeny and Symptoms. — The degree of fecal retention which 
constitutes constipation is not the same for all individuals. There are 
many — a majority, probably — who have a daily evacuation ; others 
have two, and it is by no means uncommon for those in full health to 
have a movement on alternate days. After considerable observation, 
my conclusion is, that the tendency to constipation is less harmful 
than the opposite condition. There are instances in which a state of 
health has coexisted with a very considerable degree of constipation — 
with an occasional movement of the bowels — once a week, once in two 
or three weeks, or at longer intervals, indeed. Such instances are ex- 
ceptional, but they are sufficiently numerous to justify the expression 
of the belief that the existence of constipation has not the deleterious 
effects often ascribed to it. Every individual must be regarded as a 
law unto himself, and his condition must be studied by the illumina- 
tion afforded by his peculiarities in this respect. That which is a 
condition of constipation and of evil omen in one individual, may 
be a state of relaxation and of apprehension from this cause to an- 
other. 

Constipation is accompanied by the symptomatic disturbances 
of the various maladies with which it is associated. We are here not 
concerned with these, but with the symptoms properly pertaining to 
the state of constipation. The tongue is usually coated, often heavily 
so, and the large papillae at the base of the organ are swollen and 
prominent. The breath is heavy or fetid. The sense of taste is rather 



116 



DISEASES OF THE DIGESTIVE SYSTEM. 



dulled, and the appetite is indifferent or voracious (bulimia). Very 
often the appearance and odor of cooked food excite a sense of dis- 
gust. When the stomach is empty, a feeling of depression is felt, and, 
after food, uneasiness, weight, and oppression. If any considerable 
fecal accumulation has occurred, the evidence may be afforded by the 
physical signs. Dullness of percussion along the course of the caecum 
and colon, especially over the caecum and above the sigmoid flexure 
(descending colon), will indicate the existence of fecal accumulation. 
Digital exploration of the rectum will disclose the amount of accumu- 
lation in that part of the canal. While, then, along the course of 
the colon a flat percussion note will be returned, around the umbilicus 
(over the small intestines) there may be a tympanitic sound. In cases 
of considerable accumulation, the whole abdomen may return, on per- 
cussion, a dull, even flat sound. The condition of other organs con- 
tributing to the constipation must be discussed elsewhere. 

When the desire to have an evacuation is experienced, some pain 
is felt, and the movement is effected with straining and "bearing 
down." If the faeces have formed in a solid and dry mass, there may 
be, and often is, no little difficulty in effecting its expulsion. The 
sphincter ani is widely distended ; the mucous membrane splits with 
the force of the expulsive effort acting on the solid faeces ; more or 
less blood, mucus, and liquid faeces escape ; and, finally, by a prodigious 
effort, only comparable to the pangs of labor, the hardened faeces are 
expelled in a large cylindrical mass. So severe the pain, so violent 
the expulsive effort, and so much injury done to the parts, that the 
system at large participates in the effects ; the pulse becomes feeble, 
the face grows pale, and a clammy sweat bedews the surface. In 
some instances, especially in old persons having weak abdominal mus- 
cles, the contractile efforts of the muscles concerned in defecation 
are unequal to the task of expulsion, and hence the faeces, despite all 
their efforts, can not be propelled beyond the rectum', and then me- 
chanical means become necessary to remove the accumulation. 

The fact should not be overlooked that very considerable accumu- 
lations of solid faeces may take place, although apparently daily evac- 
uation of rather liquid stools may occur. This paradoxical condition 
is due to the fact that the solid matters collect in the sacculi of the 
large intestine, leaving a central canal through which semi-solid and 
liquid materials may pass. It follows that with extensive fecal accu- 
mulation there may be daily, even more frequent, discharges. The 
author has encountered this state of things, more especially in old 
men, in whom a gradual and long-continued accumulation of the faeces 
has so lessened the perceptive and reflex activity of the mucous mem- 
brane, that hardly any extent of accumulation sufficed to excite the 
peristaltic action. Extensive accretion of faeces in the rectum has, in a 
few instances, been mistaken and treated for scirrhus. In women at 



CONSTIPATION. 



iir 



all ages after adult life such fecal collections may form in the large 
intestine, especially in the caecum and rectum. When, at last, the 
bowel contracts on its contents, very great pain is felt, the expulsive 
efforts are severe, and, finally, the accumulated mass is discharged. 

More frequently, in cases of constipation, the retained faeces assume 
a globular shape (scybala), and are apt to be coated with mucus. 
When a movement of the bowels takes place, instead of a proper evac- 
uation, there will be discharged a few of these round balls. The color 
of the faeces is, in simple cases of constipation, not altered ; but when 
the torpor of the bowel is secondary to hepatic disease — to catarrhal 
jaundice, for example — the absence of bile-pigment makes a difference 
in the character of the stools. 

In that form of constipation known as habitual, and in which the 
intestinal torpor is the substantive disorder, there are disturbances 
which properly belong to it. Fecal accumulation, by interfering with 
the return of blood from the inferior haemorrhoidal veins, will cause 
them to swell, and, pushing before them the mucous membrane, will 
form haemorrhoidal tumors or piles. By the same mechanism, conges- 
tion of the other pelvic viscera will be induced, and hence menorrha- 
gia, catarrh of the uterus, dysmenorrhoea, etc., will result. In other 
instances fecal accumulations, by pressure on the nerves, may set up a 
degree of irritation sufficient to eventuate in a formidable sciatica, or, 
by pressure on the spermatic vein, to cause varicocele, or, on the as- 
cending vena cava, to produce a varicose state of the veins in the 
inferior extremities. 

The long-continued retention of hardened faeces has, finally, an 
effect on the mucous membrane ; a catarrh is gradually set up, and, 
the irritation gathering strength with its persistence, a profuse diar- 
rhoea ultimately results. It happens in this way that, in many cases 
of constipation of a persistent character, diarrhoea alternates with a 
suspension of action or constipation. For a time the bowels will be 
exceedingly torpid ; then there will occur more or less pain, flatulence, 
tormina, etc., and a profuse diarrhoea ; after which the ordinary torpor 
will come on, to be followed ultimately by an acute catarrh again. In 
some instances, but rather rarely, the irritation of hardened, retained 
faeces sets up a croupous inflammation, and thus to constipation will be 
added a membranous enteritis. 

It is not always easy to separate the symptoms due to constipation 
from those of which constipation is a mere sign. ^N'evertheless, there 
are some clearly referable to this condition. When constipation has 
existed for some time, the nutrition is impaired. The intestinal diges- 
tion and absorption become languid, and hence the function of pri- 
mary assimilation is inefficient. The result of this condition is shown 
in the thinness of the body and the diminished muscular activity. 
Under these circumstances, also, the products of intestinal digestion 



118 



DISEASES OF THE DIGESTIVE SYSTEM. 



enter the blood in an imperfectly elaborated form. Various secondary 
disturbances occur. There are, for example, certain disorders of the 
skin produced in this way ; as, psoriasis, eczema, erythema, urticaria, 
lichen, etc. If the constipation and the causes producing it are re- 
moved, the cutaneous manifestations also disappear. Without the 
evidence afforded by a defined eruption, the functions of the skin are 
recognizably altered by the condition of constipation. The cutaneous 
. secretions are deficient, the epidermis is dry and harsh, the circulation 
languid, so that the extremities are cold, and the hair and nails are 
brittle and wanting in a proper physiological activity. 

There is an intimate association between the intestinal and cerebral 
functions. This fact was recognized by the ancients in the term hypo- 
chondria — under the ribs. They found that, with a certain depression 
of the feelings, with melancholy, there occurred disorders of intestinal 
digestion, flatulence, and constipation. They had also observed the 
good effects in certain mental disorders of the more active cathartics. 
As with the condition of constipation, and the consequently impaired 
primary assimilation and lessened excretion by the intestinal glands, 
various effete products accumulate in the blood, it follows that the 
cerebral organs must be affected by them. Hence follow headache, 
hebetude of mind, vertigo, etc. The eminent writer who prepared 
himself for his task by taking a brisk cathartic, practiced an emi- 
nently rational expedient. Stupor in some, an obstinate wakefulness 
in others, are also caused by constipation. As the general blood- 
pressure can be lowered by brisk purgation, it follows that the state 
of the intra-cranial circulation is affected by constipation. • 

Various circulatory disturbances are produced by constipation, and 
mention has been made of haemorrhoids and hjemorrhages. When the 
general cavity of the abdomen has been filled out by retained faeces, 
the column of blood in the ascending vena cava is pressed upon, and 
hence the return of blood from the inferior extremities is impeded. 
It follows, from this mechanical obstruction, that oedema of the ankles 
takes place, and this result is the more apt to occur if the subject is 
obese, since the intra-abdominal pressure is the greater the more fat 
is contained in the omentum. Whenever the ankles swell, great anx- 
iety is felt by the patient lest dropsy is about to develop. 

Constipation also increases the secondary results of pulmonary 
obstruction. When, in consequence of mitral lesions or lung-diseases, 
the venous circulation labors, and the right cavities of the heart are 
overladen, fecal retention adds materially to the obstruction. 

It follows, from the foregoing considerations, that constipation must 
be regarded from two points of view — as the sole cause of the morbid 
state, and as an important element in the pathological complexus. 

Treatment. — Constipation is readily overcome for the time being 
by the administration of purgatives, but this practice can not be ap- 



CONSTIPATIOX. 



119 



proved. The habitual use of purgatives — of purgative medicines and 
of purgative mineral waters— only increases the disability which they 
were intended to remove, for the bowels, becoming accustomed to the 
stimulation, will not act without it after a time. Before deciding on 
the treatment, a careful survey should be made in every case, and the 
causal condition should be ascertained, and efforts made to remove it. 
Is secretion insufficient? Is the bile or the intestinal juice wanting? 
If this be the causative state, remedies to promote these secretions are 
necessary. If the motions indicate the absence of bile, phosj^hate of 
soda or sulphate of manganese will be found effective ; the latter espe- 
cially, if there be a gouty habit ; and the former, combined or not 
with arseniate of soda, if there be a tendency to contraction of the 
liver (cirrhosis). If the state of constipation be habitual, associated 
with paresis of the muscular layer of the bowel, and also deficient se- 
cretion, the best results may be expected from physostigma (tincture), 
nux vomica (tincture), and belladonna (tincture), in combination. The 
action of these remedies may be promoted by combination with aloes 
(tincture) when the lower bowel is torpid. 

If the subject is plethoric, the secretions deficient, the muscular 
layer wanting in contractile energy, a combination of magnesia sul- 
phate (Epsom salts) with diluted sulphuric acid and sulphate of 
strychnine (one sixtieth of a grain), in solution well diluted, may prove 
highly effective. The addition of sulphate of iron renders the just- 
mentioned formula very useful in anaemic subjects, suffering under the 
same condition of the digestive tube. 

When we have to deal merely with paresis of the muscular layer 
of the bowels, the remedies must consist of those having the power 
to increase the contractile energy of this part. Nux vomica, bella- 
donna, and the warm purgatives, have this effect ; and hence a com- 
bination of these may be very useful. . To these must be added elec- 
tricity. One electrode is placed in the rectum — an insulated electrode, 
with a metal button or bulb uncovered — and the other, in the form of 
a moistened sponge, passed over the abdomen, especially along the 
course of the large intestine. Daily applications of a faradic cur- 
rent, or of a slowly-interrupted galvanic current, made as just de- 
scribed, will often effect permanent relief. Other forms of stimulation 
of the bowel may be good in these cases of torpor dependent on pare- 
sis of the muscular layer. A nightly dose of podophyllin resin, with 
the extracts of belladonna, nux vomica, and ergot, may establish a 
regular habit ; but the concurrent action of certain hygienic measures 
may be necessary. The author has known of excellent results from the 
regular use of " tamar iyidien " every night on retiring, the quantity 
being very slowly reduced as the habit of a daily movement is effected. 
This preparation, composed, for the most part, of confection of senna, 
owes its active effects to a small quantity of croton-oil which it con- 



120 



DISEASES OF THE DIGESTIVE SYSTEM. 



tains. By the addition of a very little croton-oil and resin of podo- 
phyllin to the official confection of senna, a very good substitute for 
" tamar indien " can be made. 

Hygienic means are not less important than the medicinal in the 
treatment of constipation. Regularity of habit should be inculcated. 
The patient should be instructed to repair to the closet at a fixed 
hour, selected with reference to convenience and leisure especially. 
An eifort should be made, whether the desire be present or not. 
At the same time the abdomen should be thoroughly kneaded and 
rubbed. A large draught of cold water should be swallowed be- 
fore breakfast, unless some contraindication exist. This may be 
sufficient, if a little salt — a teaspoonful — be added to the water. In 
the torpor of the bowels belonging to old people, a morning-draught 
of an alkaline mineral water — Saratoga, for example — has an excellent 
effect. In the case of the plethoric suffering from constipation, the 
purgative waters — Saratoga, Pullna, Hunyadi, and others — taken in 
the early morning, have an unquestionable good effect. Above all 
other means for removing constipation are those hygienic appliances 
derived from the natural stimulus of the intestinal movements — food. 
If there be no contraindication, those foods which leave a consider- 
able residuum — as Graham flour, rye and corn bread, oatmeal, cracked 
wheat, etc. — can be used with distinct advantage ; fresh vegetables 
of the succulent class — as lettuce, spinach, celery, onions, etc. — and 
fruits — as apples, dried peaches, figs, dates, tamarinds, etc. 

As a sedentary life induces constipation, it follows that exercise 
must be enjoined in such cases. Mere enforced exercise is not so 
beneficial as that kind of active movement necessitated by travel. 
The author has seen some cases of constipation cured by a trip to 
Europe. Horseback exercise is an excellent mode of progression when 
practicable ; but walking may always be carried out efficiently, and 
must, therefore, be chiefly depended on. The best results are ob- 
tained by a proper combination of the various curative agencies. 

OBSTRUCTION OF THE INTESTINES. 

Definition. — By obstruction or occlusion of the intestines is meant 
an arrest of the passage of their contents, by obstacles within the bowel, 
or in its walls, or in the cavity of the peritoneum. When the obstruc- 
tion occurs in the intestine after it has passed out of the cavity — as 
strangulated hernia, for example — it becomes a surgical malady. A 
great many names have been applied to this state : ileus, iliac passion, 
volvulus, miserere, etc. 

Causes. — Obstruction or occlusion of the intestines may be pro- 
duced by causes that are intrinsic, or extrinsic, but they are best con- 
sidered in three great divisions : 1. Extrinsic, or entirely outside of the 



OBSTRUCTION OF THE INTESTINES. 



121 



bowel ; 2. Conditions affecting tlie walls of the intestines ; 3. Dis- 
orders within the canal. 

1. The extrinsic causes are tumors without, compressing the intes- 
tine ; certain orifices in the peritoneum, as the foramen of Winslow ; 
bands of connective tissue, remains of former inflammation ; twisting, 
or torsion, of the bowel. 




Fig. 3.— Mode in which twisting of the bowel occurs. Fig, 4.— Constriction by a 

a, The first derangement, b, The twist. band of lymph. 



The tumors coming into relation with the intestine, and obstruct- 
ing by pressure, are of various kinds : floating kidney, displaced spleen, 
cysts of the peritoneum, tumors of the mesentery, of the ovary, etc., 
and cancer in various situations. As regards the entanglement of the 
bowel by passing into certain orifices, especially the foramen of Wins- 
low, the accident is rare (three cases recorded), but a number of ex- 
amples have now been noted of retro-peritoneal hernia, first accurately 
described by Treitz.* The duodeno-jejunal flexure is embraced in a 
fossa formed by a fold of peritoneum, " continuous on its inner side 
with the peritoneum covering the transverse duodenum, and forming 
the inferior layer of the transverse mesocolon." Diaphragmatic her- 
nia is relatively more common ; Leichtenstern collected two hundred 
and fifty-two cases. There are certain weak points in the diaphragm 
— at the oesophageal foramen, just behind the sternum, the space be- 
tween the lumbar and costal parts of the muscle of the diaphragm — 
through which parts of the bowel and omentum have passed. 

Constriction by old bands of adhesion, the result of former inflam- 
mations, is much more common than the herniary protrusions. The 
adhesion of the appendix vermiformis to the abdominal wall, or to 
neighboring parts of the intestine, forms a transverse band in which a 
knuckle of intestine may become engaged. Similar bands, or bridges, 
form between the organs in the pelvic cavity, and between the mes- 
entery and intestine. Some of these bands, owing to changes made 
by the movements of organs, often quite considerable, attain to great 
lengths and form constricting loops of various kinds. Slits are found 

* Dr. p. H. Pye-Smith, " Guy's Hospital Reports," third series, vol. xvi, p. 181, " On 
Retro-peritoneal Hernia." 



122 



DISEASES OF THE DIGESTIVE SYSTEM. 



in the mesentery, especially in the mesentery of the ileum, and low 
down, into which a fold of the intestine may drop and become incar- 
cerated. The extremity of diverticula becoming attached by bands of 
lymph, also form openings into which the intestine may pass. There 
is, indeed, almost no limit to the forms and varieties of constricting . 
bands for the incarceration of some part of the intestine. 

Occlusion may be brought about by twisting (torsion) of the bow- 
els. The sigmoid flexure is especially liable to this accident, owing to 
its shape and to congenital defects, and next the caecum ; rarely does 
this accident happen to any other part of the canal. I owe to Dr. 
Starck, of this city, the details of a case of this kind, in which two 
inches of the upper part of the ascending colon slipped over the part 
below. In the preliminary changes which occur in the sigmoid flexure 
preparatory to torsion, the mesenterial root shrinks and the two ends 
of the fold approximate, so that twisting can easily occur if the pe- 
ripheral part of the fold is full of fasces and therefore heavy. The 
length and weight of the fold prevent untwisting, while rapid swelling 
and distention by gas, occurring in that part of the bowel above, keep 
the fold in position.* 

While twisting of the sigmoid flexure is apt to take place in early 
life, torsion, or twisting, of the csecum is a malady of advanced life 
rather — in more than half of the cases occurring from forty-five to 
sixty years. Owing to the changes produced by old hernias, to the 
absorption of fat in the mesentery, and to paresis of the muscular layer 
with resulting accumulation of faeces, a loop of the caecum and ascend- 
ing colon forms — with a contracted mesentery — the axis of the loop ; 
the two ends of the loop approximate, and a twist may be readily in- 
duced by various forces, as sudden movements of the body, an abnor- 
mally long and full ileum, etc. 

2. Changes occurring within the intestinal tunics, such as tumors, 
polypi, hydatid cysts, carcinoma, etc., cause occlusion by a gradual 
obliteration of the canal. More frequently is the obstruction due to 
cicatrices, formed by the closure of ulcers, notably those of dysentery, 
of typhoid fever, of syphilis, etc. The most important of this group 
of causes is intussusception. By this term is meant the slipping of 
one part of the intestine into the adjacent part, so that the peritoneal 
and mucous surfaces are opposed to each other. This accident always 
occurs from above downward. Frequently, after death, there are 
found invaginations, which formed during the last moments of life, 
but they have no importance. Often a number of them exist at vari- 
ous points. 

As the part first invaginated remains at the point where it entered, 

* Dr. Kuttner, in St. Petersburg. Virehow's "Arehiv," vol. xliii, p. 478, " Ueber in- 
nere Incarcerationen." A full account of the subject, with admirable plates showing the 
mechanism of twisting. Ibid., Band liv, S. 34. Also in the same, "A Case of Internal 
Strangulation," by Jacob Heiberg, with two illustrative diagrams. 



OBSTRUCTIOX OF THE INTESTINES. 



123 



it is obvious that the increase of the intussusception is by a continued 
slipping-up of the part below. The accident of invagination may take 
place at any point of the intestines, but the most common is that of 
the ileum into the csecum, and this attains the greatest dimensions. In 
children the ileum may pass into the whole length of the colon, and be 
felt in the rectum and even pass through the anus. Other forms are 
of the ileum entirely, of the jejunum into the ileum, of the duodenum 
into the jejunum, of the colon, etc. Of all the forms of obstruction in 
the intestinal canal occurring in early life, that of invagination is most 
usual. Including all ages, half of the cases of intussusception occur 
before ten. As regards sex, males are more subject to the accident 
than females. There are two important elements in the mechanism — 
paresis, or distention, of a part of the intestine below ; spasm, or con- 
traction, of the part above. ^Yhen the bowel is undergoing irritation 
and is distended with gas, if, in consequence of the same irritation, 
violent reflex contraction of the circular fibers is induced, it is not dif- 
ficult to conceive of the suddenly narrowed portion dropping into the 
distended. Especially can we conceive this accident happening if the 
muscular layer of the enlarged portion of the bowel is in a paretic 
state, and the muscular layer in the narrowed part is in a tetanic or 
spasmodic state. A different explanation of the mechanism is made 
by others, especially by Leichtenstern, who affirms that there are two 
factors involved — a paretic condition of a part of the bowel ; violent 
peristaltic action. He supposes that the invagination occurs entirely 
by an inversion of the paretic part of the bowel, and that this inver- 
sion is initiated by the excited peristaltic action. The differences of 
opinion are not very wide, after all, and are rather in the interpretation 
of terms than of the pathological factors. When intussusception oc- 
curs at the ciecum, doubtless the same causes are at work as those 
which induce protrusion of the bowel in dysentery — a violent tenes- 
mus with paresis of the muscular layer — a condition of things which 
may readily arise in the ileum and the caecum. When invagination 
has occurred, the mesentery being drawn in with the bowel and more 
or less stretched, the circulation is greatly impeded, especially the 
return of venous blood. Swelling ensues ; the tunics of the invagi- 
nated portion of the bowel are infiltrated with bloody serum ; an 
active catarrh of the mucous membrane is established ; the perito- 
neum becomes intensely hyperjemic, and an abundant exudation is 
poured out, gluing together the contiguous portions of mucous mem- 
brane. In these cases there is not, necessarily, a complete occlusion — 
there may be still space for the passage of liquid faeces. The com- 
pression of the mesenteric vessels induces necrosis of the invaginated 
portion, which may slough off, and thus restore continuity.* It is 

* Trousseau, "Clinique Medicale," tome iii, p. 196. He has had two cases of this 
kind. 



124: 



DISEASES OF THE DIGESTIVE SYSTEM. 



necessary to this result that the invagination be equal on all sides, that 
union take place in a uniform manner around the bowel. If the invagi- 
nation is unequal and the line of union irregular after the slough 
Beparates, in the course of contraction of the cicatrix which subse- 
quently takes place, there may be produced very considerable deform- 
ity of the intestine, and its lumen seriously encroached upon. Again, 
when the slough separates, the adhesion may be insufficient, thus open- 
ing into the general cavity of the peritoneum. 

3. Causes of obstruction within the canal of the intestines are quite 
frequent — relatively more so than the extrinsic causes. First in im- 
portance is fecal accumulation, forming most frequently in the Ciecum 
and ascending colon, and in the descending colon just above the sig- 
moid flexure. Not unfrequently such fecal accumulation has for a 
nucleus an intestinal or biliary calculus. The intestinal calculi are 
composed of ammoniaco-magnesian phosphate, and the carbonate and 
phosphate of lime, with more or less inspissated mucus (enteroliths). 
Other foreign bodies accidentally present in the canal may form a 
nucleus about which the salts above named crystallize or adhere. They 
are usually oval in shape, but may have a great variety of forms, and 
they differ greatly in size, the average being about the size of a chest- 
nut. Large concretions of chalk and magnesia have formed when 
these substances had been taken medicinally for some time. Stones of 
great size have formed, alone sufficient to cause obstruction. The usual 
results of their presence, if they occasion symptoms, are attacks of in- 
testinal indigestion, colic, typhlitis, ulceration, and perforation of the 
caecum and appendix. Biliary calculi much more frequently occasion 
obstruction ; although of considerable size, they have been passed 
without any trouble. Sometimes, the symptoms of acute intestinal 
catarrh, pain, flatulence, nausea, diarrhoea, etc., are caused by them ; 
again, the bowels are obstructed more or less completely by one, or a 
succession of attacks of impaction, relief from one attack being fol- 
lowed in a few weeks by another attack of the same character, have 
been produced by a gall-stone, lodging successively in different parts 
of the ilium. Now and then complete obstruction has been caused by 
a gall-stone. They occasionally set up an ulcerative process in the 
caecum and appendix. An important factor in causing obstruction of 
the bowel is habitual constipation — that form, especially, which con- 
sists in a paretic condition of the muscular layer, and a state of dimin 
ished sensibility of the mucous membrane. Abnormal flexures of the 
colon often play an important part in causing an obstinate constipa- 
tion. Accumulations occur to a very great extent Ibehind the natur.il 
and factitious flexures, and in the caecum in old subjects especially, in 
women leading very sedentary lives, and very careless. Large accu- 
mulations are not incompatible with daily, even more frequent evacua- 
tions. The central canal may still continue open and yet enormous 



OBSTRUCTION OF THE INTESTINES. 



125 



masses remain in the sacculi. Finally, some large fecal masses drop 
into the canal, and symptoms of occlusion at once appear. 

Symptoms. — The cause and the seat of the occlusion affect some- 
what the character and development of the Symptoms, but there are 
certain symptoms common to all forms : these are pain, arrest of the 
intestinal movements, gaseous distention of the bowels, and vomiting. 
The pain is not acute and lancinating, but is severe, colic-like, with a 
feeling of soreness, and is aggravated by pressure. In the beginning 
the pain is felt about the umbilicus, in the iliac regions, and radiates 
thence over the abdomen. When tenderness to pressure exists at the 
outset, it is indicative of the seat of the lesion, but the tenderness is 
rather a feeling of soreness, and has not the painful character of the 
tenderness which is developed later on when peritonitis appears. It is 
important to note that the tenderness and pain cease when collapse 
comes on — for the author has known this to be mistaken for improve- 
ment. At first, and usually after the administration of an enema, there 
may be an evacuation from the lower bowel, and this is often a source 
of misapprehension, for it is assumed that the canal is not obstructed. 
It may be regarded as an evidence that the obstruction is above the 
sigmoid flexure, but it has no higher significance than this. At the 
beginning of symptoms — of intussusception, for example — some liquid 
fseces may escape, but presently the obstacle to the passage of fecal 
matters and of gas is complete. Even when those exceptional dis- 
charges, just referred to, escape, there is no improvement in the feel- 
ings or condition of the patient ; they do not diminish the fullness and 
tension of the abdomen. When complete obstruction has existed 
twenty-four to forty-eight hours, the abdomen is no longer soft and 
flexible, but the muscles have become rather rigid, and the whole ab- 
domen is swollen and hard, returning on percussion a note of tympa- 
nitic quality, except where an accumulation of fseces gives a different 
tone. In the further progress of the case, more and more gas distend- 
ing the intestines, they can be distinguished as inflated, sinuous cylin- 
ders : the small intestines filling the umbilical space, the large in- 
testine, the flanks, and the lower epigastric region. Not unfrequent- 
ly the abdomen is uniformly distended, the highest point in the centre 
and falling off in all directions, and the walls drawn as tense as the 
tightened drum-head. Besides the immediate and local distress thus 
occasioned, the functions of the thoracic organs are interfered with by 
the upward pressure. The respiration is thoracic, oppressed, and hur- 
ried, a distressing hiccough supervenes, and the action of the heart is 
troubled. Vomiting is a most characteristic symptom under certain 
circumstances. It sometimes begins early, immediately after the ob- 
struction, and consists at first of aliment, then of mucus, mucus and 
gastric juice, mucus and bile from the gall-bladder forced up by the 
straining. On the other hand, vomiting may be postponed until the 



126 



DISEASES OF THE DIGESTIVE SYSTEM. 



signs of obstruction are well advanced. If vomiting persists, presently 
the matters returned consist not only of greenish sero-mucus, but of 
the contents of the lower ilium, and having a fecal odor. Indeed, dis- 
tinctly formed but not molded fieces have been returned by vomiting, 
but usually it is a yellowish fluid, having the consistence of soup, and 
an odor and taste sufficiently definite. The fecal vomiting recurs from 
time to time, and, if it well empties the intestines of their contents, 
the abdominal symptoms are improved ; there is much less distress, 
and the distention is diminished, so that the thoracic organs are not so 
embarrassed, but this merely local improvement does not help the case 
otherwise. The gravity of the case is illustrated in the systemic con- 
dition, which becomes rapidly bad. There is no fever, but a tempera- 
ture below rather than above the normal. The countenance at first 
expresses great anxiety, then becomes contracted and drawn, the eyes 
deeply sunken and surrounded with a livid circle, the nose pinched and 
blue, the lips blue, the tongue dry, the voice husky and sepulchral, the 
surface of the body generally cold and covered with a cold sweat, the 
skin livid and wrinkled, hiccough persisting and more and more har- 
assing, the breathing more shallow and rapid, the temperature declin- 
ing a degree or two Fahr. — such is the complexus of symptoms in the 
approaching collapse. Usually the mind is clear and the anxiety great, 
but there may be an inexplicable apathy, and in rare cases acute de- 
lirium. Toward the close, the increasing difficulty in hsematosis devel- 
ops carbonic-acid poisoning, and then stupor ensues. The symptoms 
of occlusion, due to invagination, differ somewhat from the other forms 
of obstruction, and must therefore receive attention. The attack usu- 
ally sets in suddenly as the intussusception occurs quickly, and the first 
symptom is violent, colic-like pain, which is followed by vomiting, the 
more prompt and certain the nearer the trouble is to the stomach. In 
children the first colic-attack is followed after a few hours by relief, 
which continues for several hours until a new seizure ; but in the case 
of adults the pain which marks the occurrence of the intussusception 
continues for several days, after which it is paroxysmal, there being 
intervals of exemption from suffering. A very troublesome diarrhoea 
is coincident with the invagination, from ten to twenty, or even thirty 
discharges occurring daily, and these soon assume a dysenteric charac- 
ter, owing to the intense congestion of the intestine at the point of in- 
vagination. This symptom has greater significance, because no other 
form of occlusion of the bowel presents it. The tenesmus is all the 
more severe when the bowel descends into the rectum, as it sometimes 
does in children, and with this condition may be associated involun- 
tary discharges of mucus and blood, because of paresis of the sphincter 
ani. There may be considerable variation in the meteorism in invagi- 
nation — great distention occurring immediately after the accident has 
occurred, then subsiding as the diarrhoea goes on. A cylindrical, soft, 



OBSTRUCTION OF THE INTESTINES. 



127 



yet somewhat resisting tumor can often be detected on palpation, 
when the invaginations are in certain places : in the caecum, transverse 
and descending colon, and at the sigmoid flexure. It is especially in 
children and in the chronic cases that these invagination tumors can 
be detected. There are peculiarities about these tumors which should 
be noted : they change in position somewhat, and in form, under the 
influence of peristaltic movements excited by the necessary palpation, 
or occurring spontaneously. In children the descent of the ilium is so 
very rapid that the rectum may be reached on the second day. An 
intussusception may induce obstruction at once, and death occurs in 
from three to six days, partly by exhaustion, partly by the local in- 
flammation. In other cases, after the immediate closure of the bowel, 
the canal is partly restored by a subsidence of the local congestion, or 
the obstruction has at no time been complete : diarrhoea of an exhaust- 
ing kind comes on ; gangrene of the invaginated portion takes place ; 
and in children death ensues from the fourth to the seventh day, but 
in adults the fatal result is postpolied to the second, third, and fourth 
week, according to the acuteness of the symptoms. When, in the pro- 
cess of separation of the invaginated portion of the bowel already 
described, the discharge of the gangrenous parts takes place, it does 
not always occur in its entirety, but shreds and masses of various sizes 
are cast off, so that, indeed, the fact of such sloughs being present in 
the evacuations may escape detection. In the only case of invagina- 
tion in which the bowel itself sloughed off in its entirety, in the prac- 
tice of the author, the lost piece, a part of the ilium, was eight inches 
in length, entire as respects the presence of all the layers of the bowel, 
and showing the evidences of gangrene only at the line of separation. 
This occurred on the eighteenth day of the disease, the patient recover- 
ing. Again, cases of intussusception become chronic, last for months, 
even for a year or two, and then recovery ensues, or death takes 
place by gangrene, by perforation, by peritonitis, or by all of these 
accidents combined. 

Diagnosis. — The diagnosis involves the two questions — 1. Of the 
form of disease causing obstruction ; 2. Of the seat of the obstruction. 

1. Form of Obstruction. — This is usually a matter of inference ; 
nevertheless, there are considerations which may conduct the observer 
to right conclusions. Palpation and inspection of the rectum may de- 
termine the existence of a tumor, an enterolith, or fecal accumulation. 
Fecal accumulations may also be distinguished by palpation at the 
sigmoid flexure and at the caecum, and the diagnosis may be aided by 
the history of constipation. The occurrence of previous attacks of 
hepatic colic, if within a reasonable period, would be a presumption in 
favor of obstruction caused directly by a biliary calculus, or of impac- 
tion, the calculus serving as a nucleus for the formation of fecal 
masses. If attacks of typhlitis, of pelvic peritonitis, or of peritonitis 



128 



DISEASES OF THE DIGESTIYE SYSTEM. 



in other situations have occurred before, it may be that a knuckle of 
intestine has been fastened by such a band. If a floating kidney or 
other tumor has been known to exist in a situation to compress the 
bowel, when sudden occlusion occurs, the cause will be at once sus- 
pected. 

2. Seat of Obstruction. — The diagnosis of the position at which 
obstruction has occurred is a little less uncertain than the determina- 
tion of the form of disease. 

The distention of the abdomen — the meteorism — may furnish val- 
uable diagnostic indication. When the colon at its lower part is 
obstructed the rectum will be empty, but the transverse and ascend- 
ing colon will form a prominent roll, the rest of the abdomen being 
relatively sunken. Ultimately the stretching of the large bowel will 
render the ileo-caecal orifice incompetent, and then the small intestines 
will be inflated and the whole abdomen swollen. When, as is so fre- 
quently the case, the obstruction is at the ileo-caecal valve, the whole 
of the large intestine will be empty, and then the flanks, and the epi- 
gastrium will be relatively flat and sunken, while the center of the 
abdomen, all around the umbilicus, will be prominent and distended. 
By palpation and percussion the situation of a tumor, or of a fecal 
accumulation, can be made out. 

When obstruction occurs in the jejunum or duodenum, the course 
downward into collapse is more rapid, the vomiting and hiccough more 
persistent and exhausting than when the same obstruction exists at 
other points. Furthermore, the abdomen is not distended, may be re- 
tracted even, and the vomited matters contain no faeces. The urine is 
scanty in obstructions high up, and plentiful when the obstacle is low 
down in the colon. 

If the symptoms have occurred suddenly, and are very acute, espe- 
cially if peritonitis is present, a tight strangulation is probable — behind 
a band, in a slit in the omentum, or beneath the attached appendix.* 
If acute symptoms of obstruction have set in after some violent mus- 
cular efforts — as jumping — the patient previously free from disease, a 
twist in a loop of intestine has probably taken place. Has blood passed 
by stool in a child who has suffered from diarrhoea, and the symptoms 
of occlusion have come on suddenly, intussusception is the most prob- 
able nature of the accident. Whenever symptoms of obstruction occur 
in a woman who has borne many children, or is the subject of external 
hernia, or in one who has had attacks of peritonitis, the existence of 
strangulation by bands of adhesion is very probable. f 

Course, Duration, and Termination. — All of these points have been 
more or less discussed, but some additional observations may be neces- 

* Bryant, " The Medical Times and Gazette," vol. i, 1872, p. 363. 
f J. Hutchinson, ibid., vol. i, 1858, p. 34. 



OBSTEUCTION OF THE INTESTINES. 



129 



sary. The various occlusions, even when they have existed to a partial 
extent for a long time, begin suddenly and with violent symptoms ; 
their course is rapid, and they terminate in recovery, in partial recovery, 
in peritonitis, with or without perforation or gangrene. Peritonitis is 
a common result. It is announced by greater fullness of the abdomen, 
increased embarrassment of breathing, more frequent vomiting and 
hiccough, rise of temperature, and deepening of the collapse. The 
duration in the average is, according to Leichtenstern, six days ; but a 
child may be killed by the shock of an intussusception in a few hours. 
They may last two or three weeks. 

Prognosis. — In every case of occlusion the prognosis is grave ; for, 
although even very unpromising cases may yield to treatment, the 
result is so usually fatal that the most guarded opinions only should 
be given. The prognosis is more favorable in cases of impaction by 
faeces than in any other form of obstruction. 

Treatment. — Until the character of the obstruction is ascertained, 
no attempt should be made to procure a movement of the bowels by 
~* active purgatives or by enemata. If impaction be discovered, the 
treatment already described should be put in force. If intussuscep- 
tion be the cause of obstruction, then certain kinds of enemata are 
used. Nevertheless, the rule holds good that in obstruction all violent 
and perturbing measures are improper. On the other hand, the utmost 
quietude is necessary, in respect to the movements of the patient as 
well as to the use of remedies. Foremost, and above all measures, 
stands opium, administered with the view to maintain a quiescent state 
of the intestinal canal, and not less for its influence over the inflam- 
mation and spasm which arise in the course of the various obstructions. 
The most effective mode of administration is by the hypodermatic 
injection of morphine. The quantity is measured solely by the effect 
produced. There should be sufiicient morphine administered to quiet 
the pain, to lower the pulse, and to maintain a state of somnolence 
from which the patient may be easily aroused. This is accomplished 
in adults by one fourth of a grain of morphine and j^-q grain of atro- 
pine for the first injection, and by one eighth of a grain subsequently, 
and every four to six hours, according to the degree of effect. With 
each subsequent dose from the first, the quantity of atropine should 
not be greater than of a grain, for the effect is much longer main- 
tained than is the case with morphine. When impaction exists, the 
use of the opium would seem not to be indicated, since constipation is 
a leading factor, but even in these cases the result of its administra- 
tion is much more favorable than the treatment by purgatives, which 
in vain are used to overcome the obstacle ; while, if the opium be per- 
sisted in, the bowels move spontaneously. Purgatives failing to re- 
move a fecal accumulation, an invagination, or internal strangulation, 
increase all the dangers— of gangrene, of perforation, and of peritoni- 
tis. Although this agent is more effective when used in the form of 
11 



130 



DISEASES OF THE DIGESTIVE SYSTEM. 



morphine subciitaneously, various preparations of tbe crude drug may 
be administered by the stomach or by the rectum, the object in view 
being the same. Next to the subcutaneous method, probably the most 
satisfactory mode of administration is by the rectum. For stomachal 
use the best preparation is the official deodorized tincture. 

If the meteorism be very pronounced, this increases the difficulty 
of relieving the invagination or the internal strangulation by maintain- 
ing an over-distention of the intestine above the point obstructed. 
The gas may be safely removed by puncture with a fine, long needle 
of the aspirator. This little operation, by removing an accumulation 
of gas, has permitted the reduction of strangulated hernia, which had 
previously resisted the most skillful taxis. Experience has abundantly 
shown that the distended intestines may be punctured at various points 
without any ill result, immediate or remote.* An intussusception 
through the ileo-csecal valve or an impaction of the caecum and ascend- 
ing colon may now and then be overcome by hydrostatic pressure — by 
filling the intestine gradually with water at 95° from a reservoir placed 
at a sufficient elevation. Air or gas may be used for the same pur- 
pose. A neat way to effect it is to disengage carbonic-acid gas in the 
rectum by injecting first a solution of sodium bicarbonate, and follow- 
ing this with a solution of tartaric acid. About a drachm of each will 
be required. A firm compress must be held against the anus with 
sufficient strength to prevent the escape of the gas. Such is the elas- 
tic force of the gas that the intestine is distended, the ileo-csecal ori- 
fice expanded, and the intruded bowel forced back. For the success 
and safety of this expedient it is essential that it be used before peri- 
toneal exudation and adhesions have formed — before, indeed, the in- 
truded bowel is much swollen. If put off too long, adhesions, to 
prevent rupture into the peritoneal cavity, may be destroyed, or a 
softened condition of the bowel will yield before the pressure of the 
gas and a rent occur. For these and other reasons an experiment of 
this kind should be undertaken early. The distention of the bowel by 
air forced in by an ordinary pump may be used instead of gas, or to- 
bacco-smoke may be injected, partly to act mechanically, partly as a 
relaxing agent. The infusion of tobacco was formerly much em- 
ployed, but rarely now, as an enema to relax the muscular fiber of the 
intestine. It is a very dangerous application, and is not as effective as 
other means now used. Recently irrigation of the stomach has been 
warmly advocated. It is alleged that, by thoroughly emptying the 
bowel of gas and faeces through the stomach-tube, the distresses of the 
patient are much mitigated, and the obstruction, if due to impaction, 
invagination, or twisting, is overcome. 

Warm applications to the abdomen afford comfort, if they do not 
affect the course of the disease. If there be local tenderness — in the 

* Trousseau, " Clinique Medicale," op, cit. 



INTESTINAL PAEASITES. 



131 



right iliac fossa, for example — an ice-bag may be placed over the pain- 
ful spot, and, if the temperature is elevated, leeches may be used cau- 
tiously. Whenever, in intestinal maladies, leeches are to be applied, 
the anal region should be selected. As the strength of the patient is 
rapidly reduced, much attention should be paid to alimentation. Solid 
food should not be given. Milk, eggs, and meat- juice are proper. If 
vomiting persists, lime-water should, be added to the milk. Cham- 
pagne and cracked ice are highly grateful to the patient, and allay 
vomiting. Stimulants are required as the symptoms of collapse appear. 
Carbolic acid in mint and cherry-laurel waters is useful to allay nausea 
and to remove the fetor of stercoraceous vomiting. The author is 
aware that many practitioners administer various agents in combina- 
tion with opium, partly to increase its efficacy, it is supposed, and 
partly on account of some virtue in the remedy. Calomel is most fre- 
quently so employed, and, as the author believes, to the injury of the 
patient, except when given in very minute doses to allay irritability 
of the stomach. The relief of internal strangulation, by surgical meth- 
ods, does not come within the scope of a strictly medical treatise. The 
reader is referred to papers by Mason and Ashhurst.* 



INTESTINAL PARASITES. 

Forms. — Only those parasites having their habitat in the intestinal 
canal will be considered. Trichinosis, the most important subject in 
helminthiasis, pertains to the class of general diseases, and will there- 
fore be treated of in that connection. 

But twenty-one of the large number of parasites infesting the 
human body are found in the intestinal canal, and of these only eight 
are peculiar to man. They are as follows : 

r Taenia solium, 
Cestoda (Tape- worms) : < Taenia saginata 



Nematoda (Round Worms) 



L Bothriocephalus latus. 
Ascaris lumbricoides, 
Oxyuris vermicularis, 
Trichocephalus dispar, 
Trichina spiralis, 
Anchylostomum duodenale. 



One parasite at a time is the rule — two is not an uncommon num- 
ber ; but Rosen \ reports the case of a child four years of age in whose 
intestines there were ten lumbricoid worms, an innumerable quantity 
of oxyures, and four taeniae. According to Davaine, J children are 

* "The American Journal of Medical Sciences," 1873 and 18Y4, vols. Ixvi and Lsviil 
f " Traite des Entozoaires et des mal. Verm,," par C. Davaine. Paris, 1879. 
X Ibid. 



132 



DISEASES OF THE DIGESTIVE SYSTEM. 



more affected by nematoda (round worms), and adults by cestoda 
(tape-worms), but Heller* maintains that adults are more affected by 
both classes of parasites. 

Origin. — The doctrine of spontaneous generation having received 
its fatal blow, it is unnecessary to discuss this theory as applied 
to intestinal worms. It may be regarded as settled that the ova or 
embryos are admitted from without and conveyed into the intestinal 
canal by articles of food and drink. Hence, those who handle fresh 
meats or eat uncooked animal food are specially liable to become hosts 
of parasites, f Uncleanliness is also an influential factor, and for obvi- 
ous reasons. 

General Results of the Presence of Parasites in the Intestinal 
Canal. — There is scarcely a symptom which has not been referred to 
worms. Formerly, as an etiological factor, worms had a high degree 
of importance ; but their influence has been less and less regarded, so 
that now they are almost wholly overlooked. As is usual, doubtless, 
the truth lies between these extremes. The presence of parasites in 
the intestinal canal is not incompatible with perfect health and the 
entire absence of symptoms. The effects produced are local and sys- 
temic. The local symptoms are, disorders of digestion, abdominal 
pains, especially around the umbilicus, and an irritation, usually an 
itching, around the anus ; but the chief symptom is the appearance of 
the worm or worms. The remote or systemic signs are very numer- 
ous : thirst ; salivation ; a capricious, absent, or exaggerated appetite ; 
emaciation ; irregular action of the heart, palpitations, or intermit- 
tence of the pulse ; cough, dyspnoea, laryngismus stridulus ; disorders 
of taste, hearing, smell, vision ; convulsions — such are the varied reflex 
disturbances produced by parasites in the intestinal canal. They are, 
however, far from usual ; indeed, they are exceptional, and not deter- 
mined by the size, number, character, or position of the worms, but on 
some special susceptibility of the affected person. 

CESTODA— T-5INIA— TAPE-WORMS. 

Varieties. — Taenia saginata — beef tape-worm — ^is the form most 
common in this country ; taenia solium is occasionally encountered, 
while the bothriocephalus latus is rare. 

Causes.- — The development of taenia in its different phases has now 
been thoroughly demonstrated. Bothriocephalus latus has, however, 
thus far eluded research. A tape-worm reaches its final growth in the 
intestinal canal from an embryo — an intermediate stage in its course 
of development — admitted into the canal by means of infested meat. 
Since the introduction of the Russian method of curing diarrhoea by 
the use of finely-scraped raw meat, and the modern taste of eating 

* " Intestinal Parasites," loc. cit. 

f Cobbold, " Entozoa." London, 1564, p. 232. 



INTESTINAL PARASITES. 



133 





Fig. 5. — Trniia eolium, or solitary worm, a, 
head, or scolex; h, tape formed of many indi- 
viduals, the last of which, completely sexual, 
separate under the name of proglottides, and 
represent the adult and complete animal. Each 
Bolitary worm is a colony. — Van Bmeden. 



Fin. 7. — Bothriocephalus latus. or, scolex ; 5, the 
proglottides ; c, the sexual organs.— Van Be* 

nedtn. 





Fig. 6. — a, Rostellum ; 5, crown of hooks ; c. c, 
suckers ; 1, scolex of the taenia solium ; 2. hooks 
expanded ; a, heel of the hook. — Van JSeneden, 



FiQ. 8.— Bothriocephalus latus, egg.— Van Ben6 
den. 



134: 



DISEASES OF THE DIGESTIVE SYSTEM. 



Fig. 9.— Bothriocepha 
lu8 latus, scolex. 



rare steaks, etc., tape-worm has become more common. Taenia solium 
is derived from the embryos contained in pork, known as cysticercus 
cellulosus, and T. saginata, from embryos found in beef. The bothri- 
ocephalus is supposed to be derived from an embryo found in fish, 
but not correctly so, as it occurs among peoples liv- 
ing on the seashore and at the borders of lakes, and 
in the interior of continents as well. 

Symptoms and Results. — The small intestine is 
the abode of taenia, but when very long it may 
reach into the large intestine. The head is fixed 
against the mucous membrane just below the pylo- 
rus. The T. solium is usually solitary, but not al- 
ways, and a number of them may be found in one 
host. The immense length of the segments dis- 
charged often gives rise to the impression that there 
must be several of them to produce such a quan- 
tity. Although more frequent in adults, no age is 
exempt, and infants at the breast have been in- 
fested after feeding on raw beef -pulp. Dr. Armor* 
reports a case of taenia in an infant five days old. 
Women are more subject than men to taenia ; in 
one hundred and sixty-four cases, ninety belonged to women and 
seventy-four to males. Segments or strobila of the tape-worm colony 
pass in numbers spontaneously, and after the action of medicine^ ; and 
now and then the living proglottides migrate, crawl out of the anus, and 
are felt, cool and moist, wriggling about the hips, thighs, and genitals. 
Very rarely, portions of a tape-worm are thrown up by vomiting. The 
length of time they remain in the intestine is by no means a fixed 
period ; they have been known to exist there ten to twelve years, 
and even longer ; but there are very obvious difficulties in the way of 
accurate determination of this point. 

The presence of a tape-worm when recognized by the patient induces 
serious inquietude of mind, but not necessarily any disturbance of the 
bodily functions. Not unfrequently, a tape-worm produces, absolutely, 
no symptoms. The degree of disturbance caused is determined by the 
characteristics of the affected person — they who suffer much are ner- 
vous and easily susceptible to impressions of all kinds. In a large 
proportion of cases, the presence of the proglottides in the evacuations 
is the first intimation of the presence of the worm in the intestinal 
canal. The principal symptoms are : emaciation, notwithstanding an 
inordinate appetite ; a feeling of lassitude ; colicky pains felt through 
the abdomen ; palpitation of the heart, faintness ; salivation ; disor- 
dered digestion ; pruritus of the anus and nose ; disorders of the special 
senses, notably feebleness, etc. Sometimes the disagreeable feelings in 



* " New York Medical Journal," December, 1871. 



IKTESTIXAL PARASITES. 



135 



tlie abdomen are romoved by taking food. Probably the most constant 
symptom is the colicky pains felt in different parts of the abdomen ; 
but they are not always present, are intermittent, and vary as much in 
severity as in situation. Constipation is more usual than diarrhoea, 
and they may alternate. Itching about the anus and nose is a common 
symptom, and is rarely absent from one or the other situation, but 
itching of the anus is more frequent. The nervous phenomena, strictly 
speaking, are very pronounced, consisting of affections of the special 
senses, pains and cramps in the extremities, choreic seizures, epilep- 
tiform attacks, hysteria, etc. In a few cases the patients experienced 
a horrible odor, purely subjective ; others have disagreeable sensations 
excited by music ; others have impaired vision, sometimes complete 
amaurosis, now affecting one eye, now the other ; again, there are 
those who have, instead of itching, a sensation of hypersesthesia or 
anaesthesia in certain parts of the body, a momentary loss of voice or 
of memory, persistent wakefulness, epistaxis, etc. The most important 
symptom is the passage of strobila, or, more frequently, proglottides. 
Each proglottis contains the sexual apparatus complete and a multitude 
of embryos, and has a power of motion when first detached from the 
strobila or tape-worm colony. It is then a segment — a moist, whitish, 
cool, quadrangular body, like a bit of stout white tape, but changing 
its shape constantly so long as the power of motion lasts. Inspected 
with an ordinary pocket lens, the uterus and ovisacs, with their lateral 
branches on one side, and the testicular bodies on the other side, can 
readily be seen. It is quite possible to differentiate between the T. 
solium and T. saginata by an inspection of the proglottides — the 
former being thinner, softer, and more transparent. The lateral 
branches of the uterus of the T. solium are from nine to twelve in 
number, and of the T. sagiuata fifteen to twenty, and the latter are 
much smaller. 

Treatment. — There are two separate stages in the process of expul- 
sion of the parasite — the preparatory treatment ; the exhibition of the 
taeniafuge. The preparation of the patient consists in the use of a 
laxative to remove mucus and other matters in which the seolex, or head, 
is imbedded, and to prevent accumulation of such matters by a low 
diet, which will leave almost no residuum. Sulphate of magnesia 
should be administered each morning for two mornings before giving 
the remedy — one or two teaspoonfuls at a time in sufficient water. 
The diet should consist of milk, steak, tea, and toast, for the day 
before and during the treatment. German practitioners cause the 
patient to take certain articles which experience has shown are highly 
disagreeable to the parasite — such as garlic, onions, and salt-herring 
— and accordingly they direct a plateful of herring-salad, a savory 
dish made up of those articles, agreeable enough to Germans, but 
highly distasteful to tape-worms ! The medicine need not be given on 



136 



DISEASES OF THE DIGESTIVE SYSTEM. 



an empty stomach ; the patient may take a cup of coffee before begin- 
ning the medicine. Many remedies have been proposed, and opinions 
are diverse as to their utility. Heller prefers kousso ; Cobbold,* ex- 
tract of male fern ; while Davaine does not indicate his preference ; and 
Kuchenmeister,f after an exhaustive examination of the almost innu- 
merable methods, ancient and modern, declares his preference for the 
decoction of pomegranate. The author's experience, which has been 
not inconsiderable, is decidedly in favor of the pomegranate. The 
most successful treatment of tape-worm the author has any knowledge 
of, is that of an ignorant barber, who has a secret method which seems 
never to fail. He does not attempt any preparatory treatment, but 
administers his medicine (apparently, a decoction of pomegranate) ia 
the morning, the patient fasting, and retires from the house with the 
worm and his fee in the afternoon. 

Kiichenmeister prepares his decoction of pomegranate as follows : 

I iij of fresh bark, after macerating for twelve hours in ^ xij of water, 
are concentrated to 1 vj by a gentle heat, and this fluid is taken in 
three doses within an hour. He precedes the administration of the 
pomegranate by one day of fasting, and 3 ij of castor-oil, taken the 
night before. He prefers to add to the pomegranate the ethereal ex- 
tract of filix mas and extract of tansy, 3] — 3 ss of the former and 

3 ij of the latter. J 

Heller administers the kousso in a special manner — by the method 
of Rosenthal — which consists of compressed balls or disks coated with 
gelatine. Five drachms is the quantity required for a T. solium, and 
seven and a half drachms for a T. saginata. The gelatine-coated 
balls and disks are placed as far back on the tongue as possible 
and swallowed alone, or aided by some coffee. The tendency to 
vomit must be resisted — mustard applied to the epigastrium, small 
bits of ice swallowed, the recumbent posture maintained. Two hours 
after the last bolus, an ounce or two of castor-oil should be admin- 
istered, the object being to expel the worm speedily and entire. 
Heller affirms that this method is highly successful, but Kiichen- 
meister thinks kousso an uncertain remedy. The author's experience 
with it has been unfavorable — it expelled a large quantity of the 
worm, the segments, but not the head or scolex ; but it was adminis- 

* " Entozoa," op. cit, p. 233. 

\ " On Animal and Vegetable Parasites of the Human Body." By Dr. Frederick 
Kiiclienmeister. Sydenham Society edition, vol. i, p. 171. 

X The active principle of pomegranate — pelleterine — is now generally preferred. In 
a communication to the " Bull. Gen. de Therap.," July 15, 1879, Dr. Berenger Ferand re- 
ports comparative trials with the tannate and sulphate of pelleterine, prepared by M. Ch. 
Tanret, the discoverer. He finds the tannate more efficient. The dose is from five to fif- 
teen grains, administered fasting, the diet the previous day consisting of milk and bread. 
The remedy is followed by compound tincture of jalap, or castor-oil, or sulphate of mag- 
nesia. Tanret has put on the market, as a proprietary medicament, a concentrated fluid 
extract, which is sold under his name. The author has found it to be an efficient remedy. 



IXTESTIXAL PARASITES. 



137 



tered in a decoction, the patient swallowing a great mass of leaves, 
stems, and flowers, so that vomiting could hardly be resisted. The 
method by fern consists in the administration of the so-called ethereal 
extract — the oleoresin — in 3 ss doses, fasting. ' It is most pleasantly 
taken in perles or capsules. If of good quality, and given after suit- 
able preparation in an efficient dose, it is a successful remedy — ac- 
cording to Cobbold, the best of the group of tseniafuges. The seeds 
of the common field pumpkin is a homely but very efficient rem- 
edy, which deserves to rank among the best of the class. The fresh 
seeds are rubbed up into an emulsion by the addition of some water, 
the woody fiber separated by a coarse sieve, and the mixture drunk 
fasting. Usually no purgative is required, but one should be given 
if the bowels do not act promptly. The failures are due, simply, to 
the difficulty of retaining a sufficient quantity. A great many cures 
have been effected by turpentine ; it is, indeed, one of the most 
efficient of tseniafuges, but the natural repugnance to swallowing such 
a dose, the powerful effects produced by it, and the subsequent ill 
results, are such as to hinder its employment, and to restrict it to the 
cases which have resisted other means. Large doses, acting promptly 
as a cathartic, are not so injurious as the smaller doses which pass off 
by the kidneys. From one to two ounces of turpentine and as much 
castor-oil are administered together. Pelleterine has been used with 
increasing success since its discovery, but considerably larger doses are 
required than were at first supposed to be necessary. Preparation of 
the patient is not essential. Recently chloroform has come into use 
and is warmly commended, numerous successful cases having been re- 
ported. It is given in from 3 ss to 3 ij> mixed with twice its quantity 
of glycerin. It may be inclosed in capsules, or given in an emulsion. 
The former plan is probably more effective. The stools should be 
carefully and minutely inspected, for the medicine is not successful if 
the scolex is not expelled. The head with its row of booklets, its suckers, 
etc., can be recognized by the naked eye, but an ordinary pocket lens 
will bring out all parts with sufficient distinctness to render an inspec- 
tion positive. If the scolex is not found, and is retained, in six weeks 
to three months the segments or proglottides will be passing again. 

£othriocephalus latus is usually classed with tape- worms, and clini- 
cally properly so, but, zoologically considered, it is not a tape-worm. 
Its habitat is the small intestine — its scolex attached to the mucous 
membrane of the duodenum by its suckers. It is found more fre- 
quently in the adult and in the female. Its size is greater than that 
of taenia ; its segments are not detached at maturity, and do not main- 
tain an independent life. Detached parts of considerable extent are 
expelled at long intervals. It is ordinarily, but not invariably, soli- 

NoTE. — A combination of the most active tasniafuges, consisting of pomegranate, 
fern, koussin, etc., is prepared by several pharmacists — among them Wyeth & Brother, 
of Philadelphia — and sold as a proprietary medicine. 



138 



DISEASES OF THE DIGESTIVE SYSTEM. 



tary. According to Odier, who has observed many cases at Geneva, 
the bothriocephalous causes swellings of different parts of the abdo- 
men, irregular stools, nausea, vertigo, palpitations, night terrors, etc. 
There may be no symptoms at all, and, when symptoms do occur, 
are about the same as those already described for taenia. The expul- 
sion of the bothriocephalus is accomplished more readily than is the 
tape-worm. Kousso rarely fails. The oleoresin of filix mas is also 
successful. Kameela has been found efficient. In fact, any of the 
remedies already referred to as tseniafuges may be used against this 
worm. In Switzerland, the secret remedy of Peschier, supposed to be 
fern, is much used. 

NEMATODA— ASCARIS LUMBRICOIDES— ROUND WORMS. 

General Considerations. — The lumbrici are found under all con- 
ditions of climate— in cold, in warm, in moist, and in dry climates. 
They sometimes appear so generally as to become epidemic. In cer- 
tain epidemics of dysentery, worms in large numbers appeared in the 
evacuations. But these observations, made in the last century,* are 

open to suspicion, for in those times 
the pathological importance of worms 
was much greater than now. It is 
true, even now, under certain local 
conditions, that worms are very com- 
mon — so much so as to constitute an 
epidemic, and, in some epidemics of 
fever and of dysentery, great numbers 
of worms appear in the intestinal tract. 
The chief mode of propagation is by 
drinking-water. The ova of the round 
worm resist freezing and a very high 
temperature, and are surrounded by 
such a strong envelope as to oppose 
successfully ordinary destructive influ- 
ences, and live for years. It follows 
that, in country places, where human 
excreta easily gain access to drinking- 
water, numbers of people may be simul- 
taneously affected, or in quick succes- 
sion. Filthy habits of a people — of a 
community of negroes, for example — 
contribute greatly to the propagation of lumbrici, by the dissemination 
of ova through articles of food and drink. 

The number of ascarides existing at one time in the intestinal canal 

* Davaine, op. cit. 



FiG.lO.— Ascaris lumbricoides — 1, complete 
worm ; 2, head ; 3, tail of the male ; 4, 
middle of the body of female. 



INTESTINAL PARASITES. 



139 



is various : there may be one, two, or three worms, or they may reach 
five hundred or thousands. When very nu^merous, they may be 
grouped in rolls or bundles, distending the whole or a part of the 
intestine, or occluding it. Their place of sojourn is in the small 
intestine. They occur in early life chiefly, although Heller asserts the 
contrary, and are not common under one year and after twenty. Fe- 
males are more subject to them than males, and feeble, lymphatic, 
and strumous persons more than the robust. Poor aliment, a vegetable 
diet, and fermented drinks favor their development. Autumn is the 
season of their greatest prevalence. From their origin to the end of 
their existence rarely does more than a year transpire, but our knowl- 
edge on this point is not very definite. 

Development. — The lumbricoid worm (Fig. 10) is cylindrical in 
shape, reddish-brown or brownish-yellow in color, and tapers at both 
extremities ; but the cephalic extremity is larger, and contains at its 
summit three lips or papillae, having the mouth between them. The 
male is smaller than the female, and is distinguished by the tail being 
always turned toward the abdomen like a hook. The ova, which ex- 
ist in almost incredible numbers, are oval in shape, have an extremely 
tough, double shell, and dark, granular contents. The eggs when 
expelled are slow to develop, several months, sometimes years, being 
required. *' They do not lose their power of development for several 
years, and the young embryo, while in the shell, also retains its vitality 
for years." The subsequent steps in the development of lumbrici are 
at present quite unknown. 

Symptoms. — When few in number, as is the rule, the host being in 
good health, there are no symptoms of any kind produced by them. 
When very numerous, disorders of digestion, of nutrition, and of the 
nervous system, are caused ; but these results are not peculiar to the 
round worm, and have been alluded to in connection with the tape- 
worm. The usual symptoms are colicky pains about the umbilicus ; 
tumefaction of the abdomen ; capricious appetite, now insatiable, now 
wanting ; occasional nausea and vomiting ; sometimes diarrhoea and 
stools containing mucus mixed with blood ; whey-like urine ; itching 
of the nose and anus ; bluish coloration of the lower eyelid, dilatation 
and sometimes inequality of the pupils ; emaciation ; irregularity of 
the pulse ; choreic and hysterical seizures ; restless nights, terrors, and 
grinding of the teeth in sleep, etc. No confidence can be placed on 
the diagnosis of worms when all of the foregoing symptoms are present, 
for they are much more frequently produced by other causes. Hence, 
the diagnosis must be largely conjectural unless worms are passed from 
time to time. One or more may be found in the stools, and not rarely 
worms are brought up from the stomach, and excite gagging and stran- 
gling until disengaged from the fauces. If the symptoms above men- 
tioned persist after the ocular demonstration of the presence of worms, 
they are probably due to this cause. Chorea and epileptiform attacks. 



140 



DISEASES OF THE DIGESTIVE SYSTEM. 



in girls of eight to fifteen, may be due to the presence of worms, and 
cease on their removal— of which numerous examples have fallen under 
the author's observation. Occasionally obstruction of the intestine 
has been caused by a bundle of worms — either within the abdomen, or 
in a herniary protrusion. Requin narrates a case, the obstruction oc- 
curring at two points — in the small intestine ; at the middle of the 
transverse colon. 

Ascarides crawl up into the pharynx, the Eustachian tube, the 
nares, and the larynx. Aronssohn has collected several cases, Da- 
vaine others, of death happening suddenly with symptoms of suffoca- 
tion due to worms crawling into the larynx. Thirty-seven cases are 
reported (Davaine) of lumbrici in the biliary passages, in the substance 
of the liver, or in the cavity from rupture of the duct. The most usual 
position for them is the common duct, which they obstruct, jaundice 
results, and ultimately serious derangement of the liver ensues. He- 
patic abscess is also a result, but, very rarely, of the lodgment of a 
worm which has passed up into the body of the liver, and excited sup- 
purative inflammation. In some rare cases a worm has been discharged 
by an hepatic abscess opening externally. Worms have also been dis- 
charged externally by fecal abscesses, and they not unfrequently pass 
into the cavity of the peritoneum through perforations of the intes- 
tines. Abscess of the pancreas has been caused by a round worm block- 
ing the duct, an example of which has been reported by Dr. John Shea. 

Treatment. — There are various remedies highly effective in the re- 
moval of the ascaris lumbricoides. The most generally used is santo- 
nine, or santonic acid, the active constituent of artemisia santonica. 
The advantage of this, besides its efl[iciency, is the slight taste and ease 
of administration. It should always be explained that the vision of 
those taking santonine is affected : all objects seem as if looked at 
through yellow-colored glasses, and also that the urine is stained a 
deep yellow. In overdoses santonine causes violent nervous symptoms. 
It is given in the form of powder, rubbed up with sugar, or some ex- 
tract of liquorice — two to four grains at night, followed by a laxative 
in the morning. Calomel has considerable vermifuge property, and is 
often alone sufficient, but is now used as an adjunct to santonine, two 
to four grains given with the same quantity of santonine. This plan, 
which is very satisfactory, is still more efficient if the use of the ver- 
mifuge is preceded by hydrocyanic acid (the officinal dilution), two or 
three drops, three times a day, for iwo days. Next to santonine in 
point of efficiency is chenopodium or worm-seed, which is usually ad- 
ministered in the form of the oil. Its powerful odor and disagreeable 
taste are strong objections. Five to ten drops can be given in an 
ounce of castor-oil, or in the fluid extract of spigelia, also an efficient 
vermifuge. The fluid extract of spigelia (pink-root) may be given 
alone in from one to four drachms at a dose, or in the officinal combi- 



INTESTINAL PARASITES. 



141 



nation, the fluid extract of senna and spigelia. Any of the remedies 
named are efficient against the round worm. 



Description. — This parasite (Fig. 12) derives its common name — 
thread-worm — from its whitish appearance and size, like a bit of fine 
sewing-cotton, and from its habitat, the seat-worm. There are two 
sexes, male and female, the male being only one half the size of the 
female. The female worm is scarcely a half inch (nine to twelve mm.), 
and the male is about one fourth of an inch (three to five mm.) in 
length, cylindrical, tapering to both extremities, but the cephalic end 



Fig. 11.— Trichocephalus of Man.— 1, female: a, ce- Fig. 12.— Oxyurus Vermicularis.— 1, male ofnatu- 
phalic extremity; &. caudal extremity and anus; ral size ; 2, female, ib. ; 3, cephalic extremity, 

c, cZ, digestive tube and ovary ; orifice of sex- magnified, 
ual apparatus. 2, isolated egg. 8, male : a, ce- 
phalic extremity anus ; c, digestive tube ; 
spicula or penis ; e, sheath into which it is with- 
drawn. 



is blunter. The ova are contained in a stout envelope which resists 
considerable heat as well as cold, but softens in the intestinal canal of 
man, and discharges its embryo, which, indeed, may be discerned in 
the mature eggs already in process of development. The habitat of 
the oxyurus is the large intestine of man, especially the rectum, and 
they insinuate themselves into the folds of the mucous membrane and 
skin at the margin of the anus. They are most abundant in early life, 
and sometimes at the other extreme, in old age. 

Symptoms. — ^They excite by their presence in the rectum an intoler- 
able itching, sometimes severe pain, tenesmus usually, and these sensa- 
tions are propagated to the genito-urinary organs. The tormenting 
itching occurs at special times, and is very aggravating at night, when 
warm in bed. The stools are usually a little relaxed, fetid, and coated 



OXYURUS VERMICULARIS.— THREAD-WORM. 




142 



DISEASES OF THE DIGESTIVE SYSTEM. 



with mucus, and occasionally streaked with blood. An inspection of 
the parts discloses a reddened and roughened integument all abou' 
the anus, and excoriations of the mucous membrane caused by th( 
repeated friction of the parts. The worms may often be seen in situ. 
or in the evacuations, but it is necessary sometimes to administer ar 
injection or a laxative to procure ocular evidences of the presence oi 
these parasites. Besides the local, various reflex phenomena are in- 
duced by the irritation of the oxyurus, as epilepsy, chorea, catalepsy, 
etc. Unquestionably, excitation of the sexual organs is thus caused, 
leading to onanism. Besides the reflex, direct irritation of the geni- 
tals in girls is set up by the presence of these worms in the vagina, 
where they deposit their ova and develop in immense numbers. 
Violent local inflammation and a blenorrhagic discharge are also in- 
duced in this way, exciting suspicion of gonorrhceal infection. The 
oxyurus is not confined to the rectum, nor are its excursions limited 
to the perineum and vagina. It migrates upward into the large in- 
testine, develops in the caecum, and the lower part of the ileum is 
also invaded. So that, although the proper habitat of the parasite is 
the rectum, it should not be overlooked that they exist in the caecum 
and in the lower part of the ilium in great numbers. 

Treatment. — The fact just stated in regard to the position of these 
parasites in the intestinal canal is of great importance in the treat- 
ment. The administration of one of the vermifuges, especially san- 
tonine, aided by calomel, should be the first step in the treatment. 
As soon as this has acted, the bowel should be irrigated by a weak 
decoction of quassia or of aloes. A simple injection w^ill usually 
suflice, since the santonine has probably displaced all of the parasites 
above. The decoction should also be used as a vaginal injection, 
employing a very small tube, so that all of the canal can be reached. 
As the ova are deposited in the folds of the anus, and are not reached 
by the injections, the next step consists in carefully sponging out all 
the folds and crevices of the anus and perineum, and the external 
genitals also, with a one per cent, solution of carbolic acid. If treated 
in this thorough manner, the applications being repeated a few times, 
the parasites will be entirely destroyed, but neglect of any of these 
precautions will render repeated applications necessary. Solutions of 
carbolic acid as an injection have been used with success in the treat- 
ment of the oxyurus, but such serious symptoms have arisen in some 
cases that this practice ought not to be continued. 

Trichocephalus (Fig. 11) is rarely encountered. In respect to clini- 
cal history and symptoms, it does not differ from the round worm. 



PERHOXITIS. 



143 



DISEASES OF THE PERITONEUIM. 



PERITONITIS.— INFLAMMATION OP THE PERITONEUM. 

Definition. — Inflammation of tlie peritoneum occurs in two forms — 
acute and chronic. It may be limited to a part, or involve the whole 
of the membrane : in the former it is local, in the latter general peri- 
tonitis. It may be an independent affection, primary, or it maybe 
caused by the extension of a morbid process, from adjacent organs or 
tissues, or secondary. 

Causes. — As a primary disease peritonitis is rare, but it may occur 
at any age, even during intra-uterine life. Intense cold, severe and 
protracted counter-irritation by blisters, and blows on the abdomen, 
may excite the inflammatory process. Very much the most frequent 
cause is the extension of internal lesions of the abdomen — e. g., per- 
forations of the stomach, intestines, bladder, etc., or inflammation of 
these organs. To this category may be added the causes of pelvic 
inflammation of the uterus and annexed organs. It is not unfrequently 
an intercurrent malady coming on in the course of certain cachexise, 
as pyaemia, albuminuria, and the eruptive fevers. 

Pathological Anatomy. — The first step in the inflammatory process 
is the occurrence of hyper^emia, the capillaries being enlarged and dis- 
tended, and the blood-pressure is so increased within the area of in- 
flammation that extravasations of blood occur at various points. An 
arrest of the normal secretion and an abnormal dryness are then evi- 
dent ; next an exudation, very thin but adhesive, forms on the in- 
flamed surface and glues the neighboring parts together, but not 
firmly, for they may be easily separated. Simultaneously, a reddish, 
SGi-ous fluid is poured out into the cavity. The inflammation will now 
assume one of two directions — it will take the adhesive or exudative 
form. The fibrinous exudation already mentioned is almost pure 
fibrin and contains but few cellular elements. Presently, however, 
the cells of the endothelium become swollen, their contents granular, 
and their nuclei undergo multiplication. If, now, the process ends 
with the adhesive inflammation, the proliferation of the endothelium 
will soon be arrested, a delicate connective tissue will be formed from 
the new cellular elements, blood-vessels soon appear, and a distinct 
neo-membrane is the result, binding neighboring surfaces together, or 
forming bands of adhesion of greater or less extent. If the inflam- 
matory process assumes the other direction, the effusion increases. It 
is at first sero-fibrinous, i. e., a serous fluid, having masses of flocculi 
of lymph floating in it. The deposit of flbrin, which in the other form 
(adhesive) is slight in extent, and which disappears in the process of 



144 



DISEASES OF THE PERITONEUM. 



formation of the neo-membrane from the new cells, in this form (exu- 
dative) is very much increased, and constitutes a coating of consider- 
able thickness. The endothelium undergoes extensive proliferation ; 
the connective-tissue corpuscles of the basement membrane also, and 
new vessels develop. On separation of the fibrin layer from the serous 
membrane, the latter bleeds from rupture of minute new-formed ves- 
sels ; it appears dense, thick, and (Edematous. The swelling, hypere- 
mia, and oedema, also extend to the sub-peritoneal connective tissue, 
and ultimately to the muscular tissue, which in turn becomes softened, 
pale, and flabby. When the inflammation occurs in the peritoneal layer 
of the liver or spleen, the tissue adjacent to the inflamed membrane is 
paler than normal, softened from cedematous infiltration, and otherwise 
altered. The effusion poured out into the cavity assumes various ap- 
pearances and characteristics. The quantity varies from a few ounces, 
in the dependent parts of the cavity, up to several gallons. It may be 
sufficient to force up the diaphragm to a level with the third rib, make 
the heart lie transversely by pushing up the apex, displace the lungs, 
etc. The effusion maybe chiefly fibrinous with but little fluid. When 
this is the case, the thickest deposits are seen over the solid organs, the 
liver and spleen, and it may be general, uniting the whole surface, or 
limited in extent, forming occasional adhesions. The neo-membrane 
contains vessels, often of considerable size, and having walls of ex- 
ceeding tenuity. These vessels rupture easily, and considerable haem- 
orrhage results, a'ud this, mixed with the effusion, constitutes another 
form, the so-called haemorrhagic effusion. The adhesions, when iso- 
lated and not general, undergo great changes ultimately, by reason of 
the extensive motion possessed by the abdominal organs. They may, 
by subsequent contraction, cause great deformity of organs and seri- 
ously impair their functions, and in the case of the intestine may 
induce twisting, encroach on their caliber, and bring about slow occlu- 
sion. The small intestines may by means of such adhesions be agglu- 
tinated together, forming an almost solid mass, irregularly rounded, as 
the author has seen, in certainly one well-marked case. The effusion 
may be serous — a faint greenish, or greenish-yellow, or milky fluid, 
similar to the fluid of ascites, except in the presence of flocculi of 
fibrin, bits of false membrane, and casts of cells of the endothelium. 
The effusion is sero-fibrinous, when there is a large quantity of fibrin 
suspended in it. When absorption of the fluid takes place, the solid 
exudation undergoes the changes already described. The effusion may 
be purulent. When this is the product of the inflammation, its cause 
is, as a rule, perforation and the escape of purulent or decomposing 
matters into the peritoneal cavity. When the effusion is purulent, the 
amount of fluid contained in the abdomen varies greatly. There may 
be thick masses of pus, or the pus may be mixed with a quantity of 
serum, constituting a sero-purulent fluid. 



PERITONITIS. 



145 



The changes of chronic peritonitis are similar to those of the acute 
form. There is often little or no fluid exudation, and when present is 
not abundant, and has a purulent or sero-purulent form. The princi- 
pal fact is the existence of false membrane, either general or in local 
bands. The intestines, as already described, are sometimes united in 
a bundle and form a globular mass of some compactness. Occasion- 
ally a part of the neo-membrane, especially where it has attained the 
greatest thickness, undergoes a calcareous transformation ; or it may 
become soft, friable, and granular, doubtless preparatory to absorp- 
tion, or it may be converted into connective tissue. Divided by mem- 
branous adhesions, the cavity of the peritoneum may be converted into 
various secondary cavities, some containing serous and others purulent 
collections. The latter may be converted ultimately into a cheesy 
mass. In chronic peritonitis, tubercular deposit is common, and gray 
granulations are disseminated through the false membrane and the 
sub-serous connective tissue. Tuberculous peritonitis is usually con- 
nected with tuberculous ulceration of the mucous membrane of the 
intestine, and tubercular adenitis of the mesentery, and is coincident 
with pulmonary tuberculosis. 

Symptoms. — When idiopathic or primary peritonitis occurs in a 
previously healthy individual, it sets in with a chill, an intense fever, 
and very severe local pain and tenderness. If it succeeds to a perfora- 
tion, the onset of the peritoneal mischief is announced by an intense 
pain, felt in the region of the accident, and rapidly extending thence 
over the abdomen. Then the fever movement is but slight. If peri- 
tonitis from perforation happens in the course of typhoid fever, or in 
any other adynamic state, there may be few symptoms besides disten- 
tion of the abdomen and increase of the adynamia. When it results 
from an extension of inflammation by contiguity of tissue, it is an- 
nounced by an exaggeration of the fever, by pain and tenderness of 
the abdomen, and by vomiting — the last-named symptom being espe- 
cially significant if it has not existed in the case previously. In what 
mode soever peritonitis may begin, the symptoms most characteristic 
are, pains in the abdomen, gaseous distention, rapid failure of strength, 
and fever, somewhat remittent in type, with the remission in the 
morning. The pain in the abdomen is usually an intense, cutting, bor- 
ing pain, somewhat more severe at certain places, but felt all over the 
abdomen. The slightest touch aggravates the pain, and hence the 
patient avoids movement, suppresses cough, and breathes with the 
chest-muscles. For the same reason the breathing is short, quick, and 
superficial, to avoid motion of the diaphragm. The decubitus of the 
patient is unconsciously assumed to prevent pressure of the muscles on 
the tender peritoneum. He lies on his back, if the peritonitis is gen- 
eral, with the thighs flexed on the pelvis and the shoulders elevated, 
and, when he is told to extend the limbs, he does so very cautiously and 
12 



14:6 



DISEASES OF THE PERITONEUM. 



soon abandons the attempt, his countenance as well as his expressions 
indicating the increased pain the effort has given him. In the begin- 
ning of the disease, the abdominal muscles are kept contracted and rigid 
to guard the peritoneum from injury by movement, but it is also a re- 
flex state of tonic muscular contraction, which occurs simultaneously in 
the muscular layer of the bowel, and is due to the irritation of the 
terminal nerve-filaments in the peritoneum. But paresis of the bowel 
soon succeeds to tonic rigidity, in accordance with another law — over- 
stimulation, or long-continued, exhausts the irritability of the organic 
muscular fiber. The bowel then becomes extended by the accumu- 
lating gas, and soon (on the second or third day) an extreme degree 
of meteorism is the result, which, in fatal cases, continues up to death. 
This extreme distention of the abdomen adds to the difficulty and pain 
of breathing. The sonority of the percussion-note is tympanitic over 
the course of the large intestine especially, and the abdomen generally, 
except the dependent parts in the flanks and iliac fossae, where the 
accumulation of fluid imparts to it the character of dullness. The 
normal hepatic dullness lessens materially or disappears, because of 
the displacement of the liver upward and its partial rotation on its 
long axis. The position of the dullness on percussion varies with the 
changes of position of the patient. It is occasionally possible to hear 
a friction-sound by auscultation, but the duration of it in any case is 
very brief. The tongue is coated and the appetite impaired at the 
onset. Rarely is vomiting absent. It begins soon after the disease 
sets in, and at first articles of food and gastric mucus come up, then 
biliary matters from the duodenum. Vomiting may occur sponta- 
neously, or be excited by taking medicine, food, or drink. In some 
rare cases the vomiting has been incessant, and finally stercoraceous. 
In such cases obstruction is supposed to exist, but not confirmed on 
post-mortem examination, only peritonitis being found. Constipation 
is the rule in case of peritonitis, but occasionally diarrhoea is present ; 
then, usually, some coincident disease of the bowel exists, as tubercu- 
losis or septicaemia, for example. Constipation is the necessary result 
of the paresis of the bowel ; but paralysis of the sphincter may be so 
complete as to permit the escape of fecal matters by mere pressure on 
the abdomen. An extension of inflammation to the vesical peritoneum 
causes strangury and irritable bladder. Hiccough is a frequent and 
most distressing symptom, and is due to a reflex irritation of the 
diaphragm, transmitted from the nerve-endings in the peritoneum. 
The pulse in peritonitis is small, quick, and frequent, the tension high, 
and when cardiac failure comes on in fatal cases it becomes excessively 
quick and small, and may disappear at the wrist when the heart is 
still acting. It will range in ordinary cases from 100 to 140 ; when 
collapse approaches, the pulsations may reach 160 to 200. When col- 
lapse comes on, the temperature, which had risen to 103° Fahr., sinks 



PERITONITIS. 



147 



below normal. As has been already pointed out, the respirations are 
costal in type, very shallow, and becoming more so with the failure 
of the vital powers. There is then cyanosis. The countenance is 
anxious, shrinks ; dark, livid circles surround the eyes. In collapse the 
surface is cold, wet with a cold sweat, the skin wrinkled and sodden, 
the body exhales a cadaveric odor, the voice is husky, but the mind 
remains clear though rather apathetic, and at the last the brain is 
clouded by carbonic-acid poisoning. Or, instead of an unclouded 
intellect, there may be delirium from oedema of the brain, and, ex- 
tremely rarely, unconsciousness soon after the onset of symptoms. In 
many cases, as collapse develops, the peculiar type of respiration — the 
Cheyne-Stokes respiration— appears, and is highly significant of a fatal 
termination. 

Course, Duration, and Termination. — The course of peritonitis is 
rapid, the mortality great. The usual termination is in death. When 
it arises from perforation, a fatal result may occur in two or three days, 
and, when it is idiopathic, in five or six ; but the cases of this variety 
may last two to three weeks. Peritonitis due to internal obstruc- 
tions adds to the severity of the symptoms and the gravity of the 
case, but its course, apart from the principal malady, is not well de- 
fined. The gravest cases are those which occur in the course of septic 
diseases, or are due to the escape of decomposing and irritating matters, 
by a perforation into the cavity. The only forms which may be re- 
garded as at all favorable are those due to the extension of a simple 
inflammation, by contiguity of tissue, from the abdominal or pelvic 
viscera. In these the inflammation is simply exudative and adhesive, 
or sero-fibrinous. When improvement begins, it is announced by a 
diminution of the pain, lessening of the meteorism, and cessation of 
the vomiting. A case of acute peritonitis may terminate in a chronic 
form of the disease. After a period of improvement, grave symptoms 
will again set in, induced by the changes in shape, position, and func- 
tions of organs, the result of adhesions, contractions of bands of lymph, 
etc. 

Prognosis. — The statements already made sufficiently set forth the 
grave character of peritonitis. The prognosis in the mildest cases 
must be guarded, and in all severe cases unfavorable. 

Diagnosis. — Peritonitis is to be differentiated from hysterical ten- 
derness of the abdomen, rheumatism of the abdominal muscles, and 
acute painful affections of the various organs. From hysteria it is dif- 
ferentiated by the hysterical history, by the crying, sobbing, and globus 
hystericus, by the absence of all constitutional symptoms, and finally by 
the tenderness being merely an hysterical condition, excessive on the 
surface, but permitting, when the attention is withdrawn, firm, deep 
pressure. The suffering of the hysterical state differs from real pain 
in the disproportion of the expressions and the evidences ; while the 



148 



DISEASES OF THE PERITONEUM. 



most extravagant terms are used to describe the pain, the countenance 
is placid. In rheumatism of the abdominal muscle, there will probably 
have been other cases of the rheumatismal character ; the pain is lim- 
ited to the muscles, and deep pressure does not increase it, and the con- 
stitutional state does not indicate a severe disease. In acute painful 
affections it is sometimes difficult at once to decide, but as a rule these 
begin rather more abruptly, the pain is more acute, and there is not 
usually a history of a disease from which peritonitis might be expected 
to arise. The great majority of cases of peritonitis arise from previous 
disease in the peritoneal or pelvic cavities ; it is extremely rare, indeed, 
for an idiopathic case to occur. 

CHRONIC PERITONITIS. — There are two forms : 1. Succeeding 
to the acute ; 2. Tubercular. The acute symptoms subside and there 
is a gradual absorption of the fluid portion of the exudation. A sero- 
fibrinous exudation may undergo conversion into a purulent ; the 
fever, which had diminished or ceased, rises again and takes on the 
septicsemic character — there are chills, fever, and sweats. Rapid de- 
cline of the vital powers takes place under these circumstances. Or 
the effusion may become encysted by the formation of adhesions, as 
already described, and become a pus-depot, which may be converted, 
ultimately, into a caseous or calcareous mass. In other cases these 
purulent collections behave as ordinary abscesses, and manifest a ten- 
dency to find their way externally. Abscesses formed above a line 
drawn transversely across the abdomen through the umbilicus tend 
to dissect upward, and make their way out through the lungs ; those 
below this line tend to pass dov/n along the course of the femoral ves- 
sels. Although there are many exceptions, this may be considered as 
a natural tendency. In the dissections made by these abscesses, fis- 
tuliB may be established externally, with different parts of the bowel, 
with the thoracic cavity, etc. ; or rupture may occur into the perito- 
neal cavity, again exciting fresh inflammation. The chronic, local, and 
partial peritonitis, about certain organs, may set up important changes 
by the metamorphoses of the exudation. Thus, thick and contracting 
connective tissue about the gall-bladder, and on the upper surface of 
the liver, compresses the organ, or may obstruct the hepatic duct or the 
portal vein. The tubercular form of chronic peritonitis is often asso- 
ciated with the corresponding disease of the lungs, or intestinal mucous 
membrane, or of both. Its onset is obscure, and development slow, so 
that weeks or even months may pass before the patient is so reduced 
as to take to his bed. It usually sets in by colicky pains felt especially 
during the time digestion is going on. Constipation alternates with 
diarrhoea, and there may be, but not invariably, attacks of vomiting, the 
matters thrown up consisting of mucus and greenish, bilious-looking 
matter. The attacks of vomiting may coincide with the colic-like pains. 



PERITONITIS. 



149 



The patient rapidly declines in flesh and strength. There are daily 
chilliness and febrile movement. The skin is harsh and dry ; sweating 
usually occurs at night ; the urine is scanty, high colored, and deposits 
an abundant uric-acid sediment. With the development of these 
symptoms the abdomen gradually assumes a characteristic condition. 
By the accumulation of gas in the intestine, and of serous effusion in 
the cavity, the abdomen enlarges. Notwithstanding a considerable 
effusion, it is rare that the signs and symptoms of ascites are ]3resent. 
There is dullness in the dependent parts, whatever may be the decubi- 
tus of the patient, but not such a fluctuation as occurs in ascites. The 
compression of the vessels, by the effusion within and the direct pres- 
sure of membranous adhesions, but especially the matting of the small 
intestines into a globular mass, and the pressure of this tumor-like 
body on the iliac veins, cause an extensive oedema of the lower ex- 
tremities, the scrotum, and the abdominal walls. This result is pro- 
moted by the enlargement of the mesenteric glands, which are also 
occupied by tubercular deposit. The course of this malady is slow, 
but the termination by death is not less certain. The reader should 
not overlook the distinction between a tubercular peritonitis occurring 
with tubercular phthisis and other tubercular diseases and a peri- 
tonitis in which tubercular deposit is secondary to the morbid process 
which had preceded it. 

Treatment. — When robust subjects are attacked by peritonitis, there 
can be no doubt of the utility of leeches, ten to twenty applied over 
the abdomen. In the cases of local peritonitis (typhlitis, for example), 
if the patient is not very weak, leeches are highly serviceable. There 
are few, indeed, who can not bear the loss of blood by two or three 
leeches. The time for their application is the onset of the disease, 
before solid exudations have occurred. After leeches, or at once, 
an ice-bag should be applied to the abdomen, or to the part only af- 
fected. This ceases to be useful, and is better supplanted by warm ap- 
plications, when exudations take place and the abdomen swells. With 
the first symptoms, morphine should be administered hypodermatically, 
and should be repeated every four, six, or eight hours according to the 
effect, such a degree of narcotism being maintained that pain is re- 
lieved, the pulse considerably reduced, but yet the patient is easily 
roused. Atropine should be given with the morphine. The very heroic 
use of morphine, advocated in some quarters, is not to be commended. 
The best curative results are obtained from doses that affect decidedly 
without inducing a degree of narcotism that may be dangerous. At 
the very beginning, the administration of antipyretic doses of quinine 
is in a high degree beneficial, and the effect may be maintained by fre- 
quent exhibition of smaller doses. This ceases to be useful when there 
is solid and liquid exudation. When effusion occurs, another and a 
very different kind of medication must be adopted. The decline of 



150 



DISEASES OF THE PERITONEUM. 



the vital powers must be retarded by suitable nutrients and stimulants. 
The local applications should consist of warm fomentations, mustard- 
plasters, or flying-blisters, or the tincture of iodine. By the stomach 
the salts of ammonia should be administered freely, and morphine 
continued pro re nata. Ten grains of the carbonate of ammonium, 
in an ounce of the solution of the acetate, every four hours, when 
the exudation is going on, is, the author believes, a remedy of the 
highest utility. In the peritonitis from perforation, absolute repose, 
opium, ice, and the avoidance of all foods and drinks, are the proper 
measures. 

ASCITES— DROPSY OF THE ABDOMEN. 

Causes. — The chief factor in the pathogeny of ascites is mechani- 
cal obstruction of the vessels, the portal system, and the most common 
cause of this obstruction is cirrhosis of the liver. Tumors, as aneu- 
rism of the hepatic artery, tubercle masses, cancer, and hydatids, in a 
situation to compress the portal vein, will also cause an effusion into 
the peritoneal cavity. Increase of pressure in the portal system may 
be due to obstructive disease of the heart or lungs. Again, dropsy of 
the peritoneum may be part of a general dropsy, especially in chronic 
nephritis. Accumulation of fluid is a result of peritonitis, acute or 
chronic, but this does not, properly, constitute ascites. 

Pathological Anatomy. — The amount of effusion which exists in 
ascites varies from a few ounces to many gallons. It is usually of a 
pale straw-color, or it may have a greenish tint, and is transparent, 
and may be free from flocculi, or any foreign constituents. Its reac- 
tion is alkaline, and its specific gravity below that of the serum of the 
blood. It contains albumen or albuminate of soda, but the proportion 
is less than is present in blood-serum, but greater than in other serous 
exudation except hydrothorax. The biliary acids and pigment are also 
found in the ascitic fluid, when jaundice exists, and creatine and crea- 
tinine are very common constituents. In many cases fibrin is held in 
solution, and slowly coagulates in an exceedingly fine reticulation of 
fibers. Sometimes ascitic fluid is reddish from the presence of blood 
derived from ruptured capillaries ; again, blood may indicate the 
probability of cancer. The peritoneum long in contact with fluid is 
altered in character and appearance by imbibition ; it becomes sodden, 
cloudy, and thickened, but these are not inflammatory changes. The 
distention of the cavity and the displacement of organs disturb the 
relation of the parts. 

Symptoms. — As a rule the beginning of ascites is obscure, and it is 
not discovered until the sense of fullness and tension directs attention 
to the part, or an examination of the abdomen is made for the pur- 
pose, existing lesions rendering it probable that effusion has occurred. 
An increasing fullness of the abdomen is the most important objective 



ASCITES. 



151 



Bymptom. It is not wholly fluid, but the distention is in part due to 
flatus in the intestines and fecal accumulations, the result of consti- 
pation caused by pressure on the sigmoid flexure. If the patient is 
erect, the fluid distends the iliac and hypogastric regions ; if lying 
down, the fluid flows to the sides ; if turned upon one side, the fluid 
takes a corresponding position — so that the dullness on percussion varies 
with the posture of the patient. With the increase in the amount of 
fluid the girth of the abdomen enlarges, so that in cases of large effu- 
sion the abdomen may be two or three times larger than the normal. 
When the effusion is great and of long standing, the umbilicus is 
forced outwardly, and forms a tumor with thin walls, and soft and 
fluctuating in character. The physical signs are characteristic : On 
mensuration, the increased circumference ; on palpation, a peculiar 
wave-impulse communicated through the intervening fluid, when a 
slight blow is made on one side ; on percussion, a tympanitic note 
over the distended bowel, and a region of perfect dullness correspond- 
ing to the position of the fluid. The wave of fluctuation is best felt 
by laying the hand extended flat on one side of the abdomen, and 
gently tapping the opposite side. The distended abdomen forces the 
diaphragm upward and therefore embarrasses the respiration and the 
cardiac movements ; the urinary secretion is diminished because of 
the pressure on the renal arteries and veins, and of the escape of fluid 
into the peritoneal cavity ; constipation results from the compression 
of the sigmoid flexure. The integument of the abdomen has a glis- 
tening appearance, arising from stretching and oedema, but the skin 
generally is harsh and dry. The lower extremities and the scrotum 
also are much swollen, when the ascitic fluid is sufficient in weight to 
compress the vena cava and iliacs. 

Course, Duration, and Termination. — The course and behavior of 
ascites depend much on the cause producing it. Usually the effusion 
occurs slowly, as, for example, in cirrhosis, in which disease there may 
be months occupied in producing sufficient effusion to distend the ab- 
domen. In idiopathic ascites, the accumulation may take place in one 
or two weeks. The amount of increase in the blood-pressure may 
vary greatly when an obstruction, cardiac, pulmonary, or hepatic, is the 
cause of the effusion. Idiopathic ascites is shorter in duration than 
the other forms, and terminates in health in a few weeks. The dura- 
tion of the other forms is a question of the course and behavior of the 
malady, of which ascites is usually a symptom. When dependent on 
obstructive disease of the heart, lungs, or liver, especially the liver, 
the duration is indefinite. The fluid may be removed by treatment, 
and return again and again, for the original cause remains. 

Prognosis. — The question of recovery is determined by the presence 
or absence of certain organic changes. If the effusion is simply peri- 
toneal, the prognosis may be favorable. If it is a symptom of cardiac, 



152 



DISEASES OF THE PERITONEUM. 



pulmonary, or hepatic disease, the prognosis is unfavorable, for these 
maladies being incurable the effusion will recur, if at any time it may 
be removed. 

Diagnosis. — Ascites must be differentiated from ovarian tumors, 
pregnancy, distended bladder, chronic peritonitis, and enlarged spleen. 
As ovarian tumors are so often accompanied by effusion into the peri- 
toneal cavity, mistakes are frequent, ovarian tumors being confound- 
ed with ascites, and vice versa. The distinction lies in the following 
considerations : Ascites is almost always preceded by obstructive 
diseases of the heart, lungs, or liver, especially by cirrhosis, and the 
derangements of health which the existence of these obstructive dis- 
eases always implies. Ovarian disease does not necessarily impair the 
health, and is not preceded or accompanied by the lesions pertaining 
to ascites. 

In ascites the enlargement of the abdomen is uniform, begins at 
the dependent part, whatever that may be, and the dullness on percus- 
sion changes with the position of the patient ; ovarian tumor begins 
in the iliac fossa of either side, the growth is obliquely upward, does 
not change its position according to the posture of the patient, nor 
does the dullness change. The tympanitic percussion-note, derived 
from percussion over the distended intestines, is in ascites above the 
fluid ; in ovarian tumor, to the side and behind. When fluid in the 
cavity coincides with a tumor, the latter may be felt by suddenly dis- 
placing the fluid, and coming down on the tumor with the hand. An 
exploration through the rectum, by the method of Simon, will enable 
a diagnosis to be made at once ; by conjoined manipulation through 
the vagina, a tumor can usually be easily defined. In pregnancy the 
tumor develops in the middle line of the abdomen with an inclination 
to the right ; it is firm, inelastic, and non-fluctuating. Changes in the 
length, density, and size of the neck of the uterus, and in its functions 
(arrest of menstrual flow), and in the mammae, with the other evidences 
of pregnancy, accompany the growth of the uterine tumor. After the 
fourth month the sounds of the foetal heart and the placental soufile, 
together with the hallottement^ indicate the nature of the case without 
doubt. The author has known a distended bladder mistaken for ascites. 
Applying the same method already described for the diagnosis between 
ovarian tumor and ascites, the difference becomes at once apparent. 
In all cases of critical examination of the pelvic organs, the catheter 
is used, or ought to be, to prevent error and to facilitate the exploration. 
The local and physical signs may be precisely the same in ascites and 
chronic peritonitis, but the clinical history is so different that a differen- 
tiation may be made by reference to the origin, causes, and symptoma- 
tology of the two affections. Peritonitis is accompanied by pain and 
tenderness of the abdomen, by an increased thickness of the walls, by 
persistent vomiting, and by alternating constipation and diarrhcea ; in 



ASCITES. 



153 



ascites there is usually no tenderness, the walls of the abdomen be- 
come very thin from absorption of fat and atrophy of the muscles, 
there is no vomiting except such as is due to hepatic disease, and there 
is persistent constipation. The spleen may be uniformly and exten- 
sively enlarged so as to fill the cavity, but it differs from ascites in the 
following particulars : The enlargement is from the left hypochon- 
drium downward ; it is firm, inelastic, and non-fluctuating ; the dull- 
ness maintains with the tumor a constant position, which does not fol- 
low the movements of the patient. 

Treatment. — There are, besides artificial means, two outlets to the 
effusion — by the intestinal canal ; by the kidneys. 

Dry diet has, from the earliest period, been regarded as a most 
efiicient plan of treatment. As it may be tried without interfering 
with the remedial management proper, it should be enforced in suit- 
able cases. Dry diet consists in absolute disuse of fluids of every 
kind, and the use of water-free food. It is extremely irksome, but, if 
patiently carried out, will contribute materially to relief or cure, as 
either may be practicable. If this method be unavailable, the oppo- 
site plan, or the free use of water and diluents, should be enjoined. 
The best of all diluents for this purpose is skimmed milk, which 
should be taken with regularity and in as large quantity as the pa- 
tient can bear. An intelligent medicinal treatment of ascites must 
be conducted with reference to its cause. Here only the remedies for 
the removal of the effusion can be discussed. As the cavity is a closed 
sac, diuretics are not very efficient. The treatment by hydragogue 
carthartics is the most generally serviceable, and of the remedies be- 
longing to this group the most useful is the compound jalap powder. 
Several watery evacuations must be passed daily to make any impor- 
tant impression on the effusion ; this result is most easily accomplished 
by the administration of one or two drachms of the compound jalap 
powder in the early morning, to avoid interference with the digestion. 
If the jalap is not efficient, elaterium may be substituted ; but in the 
author's experience the former is to be preferred. Notwithstanding 
the little utility of diuretics, advantage should be taken of any good 
arising from them. The resin of copaiba, according to Wilks, is an 
efficient diuretic in this disease. Cream-of -tartar is also useful. Digi- 
talis, especially in the form of infusion, is the best of the diuretics 
proper. These remedies may be given jointly. To urge the kidneys 
to their highest activity, the functions of the skin should not be ex- 
cited, and the cutaneous capillaries must therefore be kept contracted 
by lessening the warmth of the covering or clothing. An increased 
action of the skin is generally more serviceable in ascites than diuretics 
are, unless an obstructive cardiac or pulmonary disease is the cause of 
the effusion. Most excellent results are now obtained from the use of 
jaborandi or pilocarpine in the treatment of ascites. Warm clothing. 



154 



DISEASES OF THE PANCREAS. 



vapor-baths, and pilocarpine may be used jointly, to maintain constant 
diaphoresis. Removal of the fluid by tapping is a useful expedient in 
cases not relieved by the methods advised, but so rapidly does reac- 
cumulation take place that this measure should not be practiced too 
early. It should not be adopted until the embarrassment of breathing 
is so great as to prevent sleep. The relief it aifords is immense, and 
is accomplished now so readily that there is a constant temptation to 
employ the aspirator trocar before the proper time has arrived. The 
puncture is made in the middle line — the linea alba — two or three 
inches below the umbilicus. It is not necessary to draw off all the 
fluid, but a sufficient quantity to afford relief. The puncture should 
be carefully closed. It is sometimes difficult to do this, and the 
ascitic fluid is permitted to drain away indefinitely ; but the prac- 
tice is bad, for the admission of air to the cavity sets up a septic pro- 
cess, and may excite a fatal peritonitis, as the author has seen. 

IDIOPATHIC SUPPURATIVE PERITONITIS is a term applied to 
a form of peritonitis apparently arising from exposure to cold, and oc- 
curring in children. It has the clinical history of peritonitis — -sudden 
onset, fever, small pulse (dicrotic), rapid decline in strength, pain in the 
abdomen, meteorism, nausea and vomiting, constipation, vesical tenes- 
mus. Pus may be evacuated through the rectum, bladder, vagina, or 
externally. It is in a high degree probable that the peritonitis is not 
a primary but a secondary affection, and is due to perforation. The 
enormous accumulation of gas and its extreme fetidity lend support 
to this view. Other cases having similar symptoms, and terminating 
by the discharge of matter, may be examples of the subperitoneal 
phlegmon.* 



DISEASES OF THE PANCEEAS. 



PRELIMINARY OBSERVATIONS.— So little is definitely known 
of the diseases of the pancreas that many systematic writers omit 
the subject entirely. There are, however, some practical points which 
should receive attention. The pancreas has an office in connection 
with the digestion of certain kinds of foods. Like the salivary secre- 
tion, the pancreatic fluid transforms starch into dextrine and grape- 
sugar. Although its ferment loses its activity in the presence of an 
acid, yet the pancreatic juice has the power to complete the digestion 



* See the paper by M. le Dr. Besnier, "Arch. Gen. de Med.," September, 1878. 



PANCREATITIS. 



155 



of peptones that have escaped final action of the gastric juice.* The 
emulsionizing, or preparation of fats for absorption, is another function 
of the pancreatic fluid. It therefore supplements the action of all the 
digestive juices. This fact suggests that which experiment has demon- 
strated — that the pancreas is not essential, and that the process of di- 
gestion can be carried on without its aid. The diseases aifecting the 
pancreas, in regard to which positive information exists, are pancre- 
atitis, acute and chronic, and tumors of the pancreas. 

Topography. — The pancreas lies between the xiphoid appendix of 
the sternum and the umbilicus, extends transversely about ten inches, 
and is covered in by the lower border (greater curvature) of the stom- 
ach and the omentum. The head, so called — at or near the junction 
of the epigastric with the right hypochondriac and lumbar regions — 
comes into relation to the duodenum, ascending colon, liver, gall-blad- 
der and common duct, and right kidney. Unless in the case of con- 
siderable emaciation, or enlargement of the organ, the pancreas can 
not be felt. When felt it is hard, unyielding to pressure, but a little 
mobile in position, and on percussion yields a dull, even flat note ; but 
the presence of much flatus will materially modify this result. The 
pancreas will have an apparent pulsation, in some conditions, when it 
comes to lie on the aorta. 

PANCREATITIS — In the acute form, the changes consist in hyper- 
semia, increased size and density of the organ, and, it may be, hgemor- 
rhagic extravasation. The inflammation proceeds to suppuration in a 
portion of the cases, at first in isolated depots, which may subsequently 
coalesce, forming a large one. Peritonitis may arise when the super- 
ficial parts of the organ are occupied by abscesses, and gangrene and 
sloughing may ensue when there is considerable hgemorrhagic extrava- 
sation. Almost nothing is known in regard to the causes of the dis- 
ease. Men seem to be more frequently affected than women. As 
pancreatitis seems to have occurred more often several centuries ago, 
it is highly probable that the excessive use of mercury was an eflicient 
cause. As the functions of the pancreas are merely auxiliary, it is not 
surprising that but few symptoms are produced when the organ is the 
seat of an inflammation. Pain, becoming very acute and depressing, is 
one of the earliest symptoms ; it is felt in the epigastrium, and radiates 
to either shoulder and to the back ; there are restlessness, precordial 
anxiety, faintness, nausea, and vomiting. After much straining, some 
bilious-looking watery fluid is brought up, but this does not afford 
relief. There is considerable gaseous distention of the abdomen, and 
a good deal of gas comes up by eructation. Constipation is also a 
symptom. I 

* Dr. W. Kiihne, Yirchow's " Archiv," Band xxxix, p. 130. 

f Oppolzcr, " tiber Krankheiten des Pancreas," " Wiener med. Wochcn.," 1807, No. 1. 



156 



DISEASES OF THE PANCREAS. 



From the beginning there is fever ; the pulse, at first full and tense, 
soon becomes small, feeble, and irregular. The symptoms of depres- 
sion make rapid progress, and in a few days (four to six) the patient 
is in a condition of collapse, with shrunken features, cold surface, cold 
extremities, and failing heart. The marked anxiety and depression 
from the first and the weak and irregular action of the heart indicate 
an implication of the solar plexus ; for similar symptoms are produced 
artificially (crushing-blow experiment). It will be difficult to distin- 
guish this affection from hepatic colic, or gastralgia, except by the 
fever, the rapid and irregular action of the heart, and the early col- 
lapse, which are wanting in these two disorders, which also terminate 
in a few hours — one with jaundice and returning health, the other 
with complete relief and immediate resumption of the functions. The 
termination, after a very rapid course, is usually in death ; but there 
may be a gradual decline into a chronic state, ending in abscess or 
slow induration. Acute pancreatitis may be secondary to other affec- 
tions — there may occur in it, during the course of acute infectious 
diseases, the changes included in the term parenchymatous degen- 
eration. 

SUBACUTE PANCREATITIS, according to the author's observa- 
tions, confirmed by Dr. Earle,* is a by no means infrequent affection. 
A typical case, ending in apparent recovery, and therefore not con- 
firmed by post-mortem examination, furnishes the principal data on 
which the following description is based. Since the symptomatology 
agrees in the main with the clinical features of the acute and chronic, 
or sclerotic form, it may be assumed with a high degree of probability 
that the diagnosis was correct. Various cases have, from time to time, 
come under my charge, but that above referred to seems to be the 
most complete. I supplement my own with the careful observations 
of Dr. Earle, and I avail myself, also, of the classical account of Op- 
polzer. 

The symptoms are local and systemic. The former consist in pain 
and tenderness along the pancreas, and an amount of swelling easily 
recognized in thin subjects. The pain is rather a sense of distress 
combined with heat, which radiates in all directions, but especially 
upward into the chest, and backward under the scapulae. This un- 
easiness or pain is accompanied by a sense of depression about the 
precordial region, and an actual slowing and weakening of the heart's 
action. At certain intervals, by no means regular in recurrence, par- 
oxysms of a less or more severe character occur, during which the dis- 
tress in the region of the pancreas — the soreness and uneasiness — are 



* " Cirrhosis of the Pancreas," " New York Medical Record," November 8, 1884. 



SUBACUTE PANCREATITIS. 



157 



considerably increased above the ordinary level of suffering, the 
heart's action becomes very feeble, the surface of the body grows cold 
and is covered by a clammy sweat, and hebetude of mind, or melan- 
cholic depression, comes on with the other symptoms. 

The digestion is impaired ; the food lies heavy, and constipation or 
diarrhoea occurs, but the former is more common, and they may al- 
ternate. The appetite is poor and capricious ; nausea is not usual, 
vomiting is rare, but the sensation of epigastric distress is accompanied 
by squeamishness. The stools are not healthy — have a pronounced 
and rather offensive odor, are dark in color usually, scybala are mixed 
with liquid or semi-fluid material, and they may be sour-smelling, 
acrid (presence of butyric acid), yeasty, and mixed with merely de- 
composing matters. An excess of fat may or may not be evident ; 
in my experience usually not — in this respect differing from the stools 
in cancer of the organ. 

The nutrition of the body is lowered in consequence of the insuffi- 
cient appetite, the feeble circulation, and the impaired intestinal di- 
gestion. The face has an anxious expression, the skin a sallow tint, 
often pigmented in spots, and the mucous membrane of the lips and 
cheeks is pallid, and the tongue is somewhat pointed, irregularly glazed 
and dry, and but little coated, as a rule. Some salivation is a com- 
mon symptom ; occasionally it is profuse. 

The duration of this affection is rather indefinite. After several 
weeks or months, an improvement in the general state takes place, the 
swelling and tenderness subside, the intestinal discharges assume a 
natural aspect, and ultimately health is restored. 

The termination of this disease is probably more often in intersti- 
tial pancreatitis, or sclerosis of the pancreas. When this occurs, the 
symptoms are similar in character to those of the subacute form, but 
are less sharply defined. 

The chronic interstitial pancreatitis^ affecting parts of the gland, 
is the form which the chronic inflammation most usually takes. The 
connective tissue undergoes hyperplasia, and the proper gland-struct- 
ure wastes. When the whole organ is involved, there may be an 
entire disappearance of the proper gland-structure, or a part of it may 
be converted into a connective-tissue bundle. As in cirrhosis of the 
kidney, cysts are produced by obstruction of the ducts. Calculi form 
in the ducts, and the duct of Wirsung may be entirely occluded by a 
calculus, inducing dilatation of the ducts and atrophy of the gland- 
substance. Abscesses may also result from the pressure and inflamma- 
tion caused by calculi. Chronic parenchymatous pancreatitis is a less 
usual form of chronic inflammation. It is probably more frequently 
secondary than primary — i. e., due to the extension of suppurative 
inflammation from neighboring parts. 



158 



DISEASES OP THE PANCREAS. 



The treatment must be entirely symptomatic. Pain must be re- 
lieved by morphine hypodermatically, the stomach symptoms by car- 
bolic acid, bismuth, pepsin, ingluvin, hydrocyanic acid, etc., and the 
chronic interstitial change is best treated by minute doses of corrosive 
sublimate, iodide of potassium, and similar remedies. 

CANCER OF THE PANCREAS.— Much more is known in regard 
to this than to any other affection of the pancreas. The ordinary 
form of cancer affecting this organ is scirrhus, and scirrhus character- 
ized by a denser stroma. Medullary and colloid have also appeared in 
the pancreas, but very rarely. Scirrhus of the pancreas is more fre- 
quently secondary than primary, and even as a secondary disease it 
is very rare, occurring in cancer cases in the proportion of about six 
per cent. only. It develops most frequently in the head of the pan- 
creas and occurs there as a secondary disease, and extends thence over 
the body of the organ. It is more frequently confined to the head 
than to other parts of the organ ; in 200 cases there were 33 in which 
the disease was confined to the head, and in 88 the whole organ was 
affected.* A tumor of the pancreas of considerable size must impinge 
on neighboring organs ; it may compress the ascending vena cava, 
causing oedema of the lower extremities ; the ductus communis chole- 
dochus, causing jaundice ; the pancreatic duct, causing dilatation and 
the formation of concretions ; the ureter, causing hydronephrosis, and 
the duodenum, causing stenosis and dilatation of the bowel above and 
subsequently of the stomach. It is usual for cancer of the pancreas 
to extend to and implicate other organs, which may be bound down 
into a uniform mass, in which the point of initial deposition may not 
be distinguishable. The duodenum, the stomach, the gall-bladder, 
the kidney, the liver, mesenteric glands, and peritoneum may all 
be included in a mass of which the beginning was in the head of 
the pancreas. Ulcerations into neighboring organs may also take 
place — as into the stomach, duodenum, vena cava, portal vein, splenic 
artery, etc. 

Cancer of the pancreas is more frequent in males than in females ; 
in Dr. Da Costa's f cases there were 24 males and 13 females : nearly 
twice as frequent, which is the proportion noted by other observers. 
As is the rule with scirrhus in all situations, the morbid growth makes 
its appearance from forty to sixty years of age. Pain is an early symp- 
tom, and, as it appears without cause, is persistent and rather increases 
than diminishes, and as progressive emaciation and feebleness accom- 
pany it, especially if the age of the subject be suitable, it is extremely 

* Ancelet, " Etudes sur les Maladies du Pancreas," Paris, 1866, p. 84. 
f "N. A. Med. Chirurg. Review," September, 1858, p. 883. 



CYSTS OF THE PANCREAS. 



159 



suggestive of malignant disease. The pain is situated in the epigastric 
region and radiates through the numerous ramifications of the solar 
plexus, into the back, through the abdomen ; it is pretty constant, with 
paroxysms of great severity in which the suffering is agonizing ; it is 
increased by the erect posture, and is relieved by bending the body 
forward. The presence of a tumor has a high degree of importance, 
but it is not always found, and when discovered may be misleading. 
A tumor is discovered in not more than one third of the cases, owing 
to the depth at which the pancreas lies. The head of the pancreas 
has been often mistaken for scirrhus. If enlarged lymphatics be felt, 
and especially if the cervical lymphatics are enlarged, support will 
be given to the supposition that an existing tumor is malignant. In 
a small proportion of cases, an excess of fat in the stools is a symp- 
tom which throws light on the case. The appearance of jaundice, 
the passage of blood by stool, oedema of the lower extremities, and 
disorders of digestion, are coincident with the extension of the new 
growth to neighboring organs, and rather confuse than clear up the 
diagnosis. In Da Costa's 37 cases, jaundice was present in 24, dys- 
pepsia in 25, dropsy (anasarca or ascites) in 15. With the develop- 
ment of these symptoms there is a corresponding increase in the 
gravity of the constitutional state. The general condition and the 
cachexia, such as have been described as belonging to cancer of the 
stomach, are present in these cases. The duration varies somewhat. 
The most severe terminate in a few months, and but rarely is any 
case protracted beyond a year. The rate of progress is influenced 
by the complications — by the pressure on neighboring organs and in- 
terference with their functions. Sudden death may be due to erosion 
of a large vessel. 

OYSTS OP THE PANCREAS.— Chronic interstitial pancreatitis is 
the chief factor in their causation, as in the production of the corre- 
sponding cysts of the kidneys. Ducts being obstructed by the growth 
of the connective tissue (hyperplasia), the contents of the acini — the 
secretions — accumulate, the walls yield to the increasing pressure, and 
thus a cyst is formed. Haemorrhage into such cysts, purulent trans- 
formation, and albuminoid degeneration, effect important changes in 
the contents of these cysts. Obstruction of the duct of Wirsung by 
a calculus, by neoplasms, by cancer of the duodenum and tumors, will 
cause a cystic degeneration of the whole gland. 

CALCULI OP THE PANCREAS.— These are concretions, consist- 
ing of carbonate and phosphate of lime, which have crystallized about 
a bit of inspissated mucus or other organic matter. To produce them 
there must be a catarrhal state of the mucous lining of the ducts, a 



160 DISEASES OF THE LIVER. 

change in the secretion toward an excess of its earthy constituents, or 
an obstruction leading to retention of the secretion. The pancreas is 
also liable to amyloid and fatty degeneration, and is sometimes the 
seat of secondary tubercular deposits. 



DISEASES OF THE LITER. 



TOPOGRAPHY OP THE LIVER. 

The liver, with its annexed apparatus, occupies the right hypo- 
chondrium, and extends in part across the epigastrium (Fig. 13). On 
percussion the area of the hepatic dullness is determined by the posi- 
tion of neighboring organs, as well as by those variations in the size 
of the liver due to disease and to its own normal elasticity. Under 
variations of the blood-pressure — as, for example, in mitral obstruction 
or regurgitation, and in portal stenosis — the size of the liver increases 
or lessens. Distention of the intestines with air, and emphysema of 
the lungs by increasing sonority at the borders of the liver, narrow the 
boundary of the dullness. When the patient is recumbent, the liver 
gravitates upward and backward ; when the patient is upright, it 
glides downward and forward — hence the area of dullness shifts corre- 
spondingly. Besides the variations in the area of dullness due to these 
several factors, the vertical line of dullness differs at different points : 
in the axillary line it is four to five inches, and in the mammary line 
three to four inches. There is a difference between the deep and the 
superficial dullness. On strong percussion the deeper parts are thrown 
into vibration, and hence the wider the area of dullness ; whereas on 
slight percussion the shelving margin of the lung vibrates alone, thus 
lessening the dullness. 

In health the inferior border of the liver extends to the margin of 
the ribs. If on palpation it can be felt beyond, there is probably en- 
largement of the organ, unless effusion into the thorax or a tumor, 
etc., depress it downward." In the axillary line the dullness extends to 
the upper border of the eleventh rib (Fig. 13, XI). Besides the various 
conditions external to the organ which may affect its position, it should 
not be forgotten that — as has been stated — the liver has a considerable 



TOPOGRAPHY OF THE LIVER. 



161 




162 



DISEASES OF THE LIVER. 



elasticity, and expands and contracts with the variations in the amount 
of blood contained in it. Mere change of position should not be mis- 
taken for alteration in size. It is a good plan, in exploring the topog- 
raphy of the liver, to fix first the upper border of the organ, which 
should be marked with ink, and then ascertain the inferior margin by 
percussion from below upward until the line of hepatic dullness is 
reached. 

COMPOSITION OF AND TESTS FOR BILE.— The bile is a fluid 
having a golden, reddish-brown, or greenish color, and when free from 
mucus, without viscidity. In reaction it is faintly alkaline or neutral 
— most usually the latter — and it has a specific gravity of about 1010, 
when recently secreted ; but if it is retained for some time in the gall- 
bladder it becomes darker in color, viscid from the presence of mucus, 
and more distinctly alkaline. The quantity of solids is variously esti- 
mated, according to the time it has remained in the gall-bladder — from 
two to three per cent, when fresh, and rising to ten to fifteen per cent, 
when old. 

The solids of bile consist of a coloring-matter or pigment — hiliru- 
hin or hiliverdin ; of peculiar acids, combined with soda — glycocho- 
late and taurocholate of soda ; of fatty matters — cholesterin, soaps, 
and lecithin ; and of salts — chloride of sodium, phosphate of soda and 
lime, carbonate of sodium, etc. 

The tests for bile when mixed with other animal secretions have 
not been satisfactory hitherto, nor are they now unless, indeed. Dr. 
Oliver's peptone test prove sufficient. 

Gmelin's test for bile-pigment consists in the reaction with nitric 
acid containing some nitrous, which is the case with the ordinary com- 
mercial article. There are several modes of applying it. The most 
distinctive is to place on a porcelain plate a thin stratum of urine, and 
bring in contact with it some nitric acid. At the point and instant of 
contact, a play of colors due to the oxidation of the pigment takes 
place — first, a green, then blue, violet, and red zones successively ap- 
pear. Rosenbach suggests the plan of filtering the urine, and touch- 
ing the pigment adherent to the paper with a drop of nitric acid — a 
green circle forming at the j^oint of contact. Hydrochloric acid is 
preferred to nitric by Harley. This, brought into contact with the 
urine on a white plate, gives to the pigment an olive-green tint. 

The most promising test for bile when contained in mixed animal 
secretions is that of Oliver.* It is based on the fact that an acidu- 
lated peptone is precipitated from its solution on the addition of bile. 

* London " Lancet," April and May, 1885, " A Contribution to the Clinical Study of 
the Liver viewed through the Urine," by George Oliver, M. D., London. 



JAUNDICE. 



163 



The test solution, as recommended by Oliver, has the composition as 
follows: "Pulverized peptone (Savory and Moore), thirty grains; 
salicylic acid, four grains ; acetic acid (B. P.), thirty minims ; dis- 
tilled water, eight ounces. Perfect transparency is obtained after re- 
peated filtration." The reaction is described by Oliver as follows : 
" When twenty minims of urine, containing bile salts in pathological 
quantity, are run into sixty minims of the test solution, an opalescence 
appears proportionate to the amount of bile derivative." This test is 
not only exceedingly delicate, but there do not appear to be any 
sources of fallacy in respect, at least, to the ordinary constituents of 
the urine. 

Pettenkofer's test can not be used with any degree of certainty for 
bile in complex animal solutions, such as urine, but for bile alone it 
satisfies all the requirements. It is applied as follows : In the solution 
of bile some strong sulphuric acid is put, and when the bile acids are 
precipitated more sulphuric acid is added, until they are dissolved. A 
little sirup is now dropped into the liquid, and the whole is gently 
warmed, when a fine purple color like that of a solution of permanga- 
nate of potassium is developed. Strassburg's modification of this test 
is sometimes convenient. To the mixture suspected to contain bile — 
urine, for example — a little cane-sugar is added, and a strip of filtering- 
paper is dipped into it and then dried. A drop of strong sulphuric 
acid is now let fall on the paper, when, in less than a minute, a ring of 
violet appears around the drop. 



JAUNDICE, OR ICTERUS. 

Definition. — The term jaundice, derived from the French word 
jaune, signifying yellow, means a yellowish discoloration of the skin 
due to the deposition of bile-pigment. The Greek word icterus, some- 
times used to designate this state, has the same meaning. Jaundice 
is a symptom, common to many affections of the liver. To give it 
separate consideration, as if it were a disease, is not, therefore, a logi- 
cal position, but it is the usual practice of systematic writers, and the 
author is, therefore, constrained to follow it, that his work may not 
appear deficient. 

Etiology. — There are three conditions under which jaundice may 
be produced. Hasmatogenous is that due to the disorganization of the 
blood and the separation of hsematoidin. At one time bilirubin — a 
bile -pigment — and hsematoidin — blood - pigment — were supposed by 
the physiological chemists to be identical. It would hence follow 
that, were any substance to enter the blood capable of setting free the 
coloring matter, the appearance of jaundice would result. The bile 



/ 



164 



DISEASES OF THE LIVER. 



acids were supposed to effect this change, setting free hsematoidin, 
and thus causing haBmatogenous jaundice. But the identity of the 
two pigments is no longer admitted, and the production of artificial 
jaundice has not been accomplished by injecting bile acids into the 
blood. The theory of hgematogenous jaundice is, therefore, no longer 
tenable, with the data at present in our possession. 

The existence of a jaundice by suppression was entertained for 
several centuries, and has been supported by eminent authorities of 
the present generation — by Watson,'^ Bamberger,! Budd,]; Trousseau, || 
Moxon, § and others — but is now generally abandoned except by Harley, 
who in the last edition of his work [1885] reaffirms and vigorously 
maintains his original position. To establish this theory, it is neces- 
sary to show that the bile exists preformed in the blood, and that the 
liver merely acts as a strainer, to separate it. Notwithstanding the 
detection of the bile acids is comparatively easy, neither acids nor 
pigments can be found in the blood — not even in the blood of the 
portal vein. Hence it follows that jaundice by suppression does not 
exist. 

The third theory, which is universally admitted to be true, if it 
may be by some regarded as limited in application, ascribes jaundice 
to the reabsorption into the blood of bile already formed by the liver. 
There are two conditions under which this is known to occur, and a 
third, which is supposititious. The usual condition consists in an 
obstruction of the ducts. Heidenhain has proved experimentally 
that a very slight obstacle suffices. It has been observed clinically 
that jaundice occurred when there was such a slight catarrhal swell- 
ing of the intestinal extremity of the common duct as left no trace 
after death, except the staining which marked the limit of the bile- 
flow. 

Again, bile will flow into the vessels instead of into the ducts, 
when the pressure in the former is lower than it is in the latter. This, 
Frerichs maintains, is the chief cause of jaundice, and Heidenhain has 
also proved it by direct experiment. The occurrence of jaundice by 
mental emotion can only be rationally explained by this theory. It 
has been maintained that jaundice may be produced by the absorption 
of bile that the intestines fail to dispose of. A species of circulation 
of the bile is, by Schiff, maintained to exist. That which is cast into 
the duodenum from the common duct is taken up by the radicles of 
the portal vein, undergoing changes not now well understood, but 

* " Lectures on the Practice of Medicine," Lecture Ixxv. 

f "Krankheiten des chylopoietischen Systems," p. 5lV. 

X " On Diseases of the Liver," p. 373. 

II " Clinique Medicale," tome iii, p. 274. 

§ "Transactions of the Pathological Society." 



JAUNDICE. 



165 



probably oxidation, and is again excreted by the liver. A failure to 
destroy this bile, or an excess of it, may result in the absorption of 
sufficient to produce jaundice. There is but little probability in this 
theory. 

Pathological Anatomy. — The liver being most concerned should be 
carefully examined. Obstruction of the ducts by hyperemia and 
catarrhal swelling may disappear after death. In that case, the pres- 
ence or absence of bile-staining will indicate the seat of the obstruc- 
tion. Very often the ante-mortem state is shown to have been an 
obstruction at the duodenal orifice of the common duct, by the absence 
of bile-staining here and in the neighboring part of the intestine, while 
above in the ducts the staining is well marked. A plug of mucus in 
the common duct, not stained with bile, will show that no bile has 
passed since the formation of the plug. Masses of epithelium and 
mucus may form obstructions high up in the smaller ducts. The 
hepatic or common duct may be obstructed by a calculus. Tumors, 
enlarged lymphatics, an aneurism, cancer of the pancreas, etc., may 
occlude by exterior pressure. When the obstruction, of what nature 
soever it may be, is persistent, important changes occur in the liver. 
The ducts and gall-bladder become enormously dilated — in a uniform 
or sacculated manner. The walls of the duct thicken, due to a hyper- 
plasia of the connective-tissue elements, and the follicles dilate. The 
coloring matter of the bile present in the ducts is finally absorbed, and 
only a colorless fluid remains. The substance of the liver changes, has 
a mottled appearance due to the tinting of the center of the lobule 
with a deep yellow, while the peripheral portion has a lighter yellow 
shade — changes due to the deposit of pigment. The bile when the 
ducts are obstructed passes out of the liver by the lymphatics into the 
thoracic duct, and thence into the blood (Fleischl).* The obstruction 
continuing, the depth of color in the lobules increases, changing to a 
dark green finally ; the substance of the liver becomes firmer and 
granular, enlarges a little, and then begins to shrink. If the jaundice 
has persisted for a long time, a considerable overgrowth of connective 
tissue takes place, the hepatic cells shrink, become angular, and their 
contents have a shining, rather vitreous appearance, and in some cases 
are destroyed. 

The kidneys also undergo important changes in jaundice, as Fre- 
richs was the first to show. When the jaundice has been of long 
standing, the kidneys have a deep-olive tint, the tubules are stained 
green or brown, and the epithelium is fatty, colored greenish, brown- 
ish, or black, and is largely detached. In extreme cases, the deposits 
of pigment fill the tubules with a black mass. 

^ Legg, " On the Bile, Jaundice, and Bilious Diseases," New York, D. Appleton & 
Co., 1880, p. 351. 



166 



DISEASES OF THE LIVER. 



Symptoms. — Jaundice first appears in the conjunctiva, and imme- 
diately the bile-pigments may be detected in the urine by Gmelin's 
test. Then the skin of the face appears sallow or fawn-color, quickly 
changing into yellow, and thence the yellowness extends to the chest 
and arms, to the abdomen and lower limbs, and finally the whole body 
is uniformly yellow. In slight cases, the face and thorax only may be 
tinged. The mucous membrane of the mouth is stained ; but it does 
not show in the lips, because of their redness, and is visible in the roof 
of the mouth and the soft palate. Very rarely does the saliva exhibit 
a yellow tinge, and present the reaction for bile-pigment ; but the 
milk of the nursing mother, jaundiced, contains bile, and jaundice is 
said to be communicated to infants in this way. In a very short time, 
within forty-eight hours probably, bile-pigments appear in the blood ; 
but doubts may be expressed in regard to the presence of bile acids, 
although they have been discovered in the blood of dogs whose com- 
mon duct had been tied. Becquerel and Rodier, and afterward Frerichs, 
found that there was a large increase of fatty matters and cholesterin. 
The blood is also changed, as respects the red globules, which are di- 
minished in number. The urine early undergoes a change, and becomes 
intensely colored with bile-pigment, which it imparts to linen and 
white paper dipped into it. The color varies from a simple increase in 
the depth of the normal color up to the darkness of black coffee. The 
usual tint is that of dark sherry or brandy. The urine is usually tur- 
bid on cooling, from the presence of a great quantity of urates ; is acid 
in reaction, and the specific gravity is well up toward normal. Albu- 
men, at least in traces, is rarely absent from the urine in jaundice. 
The best test for the presence of bile in the urine is the nitric-acid or 
Gmelin's test. It is best performed by pouring into a test-tube about 
an inch of nitric acid ; then let drop from a pipette some suspected 
urine on the side of the tube. As the urine comes in contact with the 
acid, if free from bile, it forms a red line on the margin of the acid ; 
but if it contain bile there will be an alternation of colors — green, 
blue, violet, and red — the green being uppermost. Although the bile 
acids have not been found in the urine, nitrogenous derivates from 
them were discovered by Hoppe-Seyler, Kiihne, and Bischoff. Re- 
cently minute traces of the bile acids have been detected in the urine 
in health. It is supposed that absorption of these takes place in the 
intestine. If jaundice has long continued, the bile acids cease to be 
produced, and hence are not to be found in the urine. The amount of 
urea present in jaundice may be normal, or above or below normal, so 
that at present no conclusions can be drawn from this fact. Casts are 
sometimes present in the urine, especially hyaline, sometimes epithelial. 

The stools in jaundice are grayish or slate-colored, sometimes quite 
white. In other cases, portions of the stools are stained with bile, 
some parts not containing any, giving them a parti-colored appearance. 



JAUNDICE. 



167 



They are often very fetid, from the decomposition of some articles of 
food, and the wind passed is equally foul. Again, they may be entire- 
ly without odor. As a rule, the bowels are rather constipated, although 
diarrhoea may occur. 

Jaundice is usually unaccompanied by pain. It is true, those cases 
due to the passage of gall-stones are preceded by the most severe suf- 
fering ; but the jaundice itself is comparatively painless. Headache 
is a common symptom ; but it is rarely considerable — often only a ten- 
sive feeling in the frontal region. Drowsiness, hebetude of mind, and 
despondency are commonly experienced. The appetite is generally 
poor, but is sometimes inordinate or canine. Nausea, a persistent and 
harassing hiccough, and a heavily furred tongue, are present in some 
cases ; in others, the digestion is good and the tongue clean. Lan- 
guor, muscular soreness, inability for any considerable exertion, and 
decline in the bodily vigor generally, are experienced in most cases. 
As that important material, glycogen, ceases to be formed Avhen the 
bile-ducts are obstructed, an adequate explanation is thus afforded of 
the decline in strength. Although various disturbing causes may alter 
the conditions, in jaundice the temperature is barely normal, or is below 
normal. It has been shown experimentally that the injection of the 
bile acids into the blood lowers the temperature. In those diseases — 
as pneumonia, for example — in which high temperature is the rule, the 
fever-heat does not attain the usual altitude when jaundice occurs. It 
sometimes happens that the temperature rises quite high — 104°, 105°, 
or 106° — at or near the termination of chronic jaundice ; but this is 
indicative of a fatal termination, and is due to or accompanied by a 
considerable disturbance of the nervous system. 

In many cases of jaundice the pulse is slow. Frerichs has met 
with a case in which it was twenty-one to the minute, but it rarely 
descends below fifty. Exercise and the occurrence of inflammatory 
action increase the pulse-rate when it is abnormally slow. The cause 
of the slow beat has been variously interpreted : it has been ascribed 
to increase of inhibition ; to the action of the bile acids on the cardiac 
muscle and on the cardiac ganglia. A murmur has also been discov- 
ered in the mitral area in the cases of slow beat of the heart, due, it is 
supposed, to diminished power in the papillary muscle, and whence 
imperfect action of the mitral- valve segment. 

More or less itching of the skin, sometimes an intolerable itching, 
is observed in many cases — probably in three fourths of the cases. It 
is sometimes preceded by nettle-rash ; and the itching may precede the 
jaundice by several days, even weeks. Sometimes the itching ceases 
when the jaundice appears ; but it comes on in most cases with the 
jaundice, and gradually declines. The itching is usually worse at 
night, and is most annoying where the clothes have pressed. The 
taste in jaundice is often bitter, and sapid articles are not rightly ap- 



168 



DISEASES OF THE LIVER. 



predated. Rarely is the vision yellow, all objects being seen through 
a yellow medium. 

In the more ancient cases of jaundice, yellow, leathery patches, 
round or oval in shape, appear on the skin, especially on the eyelids 
and hands : they are entitled xanthelasma^ and two forms are recog- 
nized — the flat and the tuberous. The change consists in a fatty infil- 
tration of the affected area. It is not necessary to the appearance of 
this affection, that the jaundice be intense, but it must be long con- 
tinued. It very rarely arises earlier than four months, and usually 
not earlier than a year, after the appearance of the jaundice. Why 
it should develop in some cases of jaundice and not in others is 
unknown. The conditions exciting it are equally obscure. It may 
slowly disappear without leaving any changes, but remedies do not 
affect it. 

Course, Duration, and Termination. — The behavior of jaundice is 
so largely dependent on its cause, that no course can be laid down 
applicable to all cases. The jaundice of acute yellow atrophy and of 
phosphorus-poisoning is of short duration and fatal, while that due to 
a permanent obstruction is most protracted. The jaundice arising 
from catarrh of the ducts depends on local conditions, which vary in 
extent and importance. The reader will find under the several mala- 
dies of the liver the manner in which the course, duration, and ter- 
mination are thus influenced. 

Diagnosis. — A simple inspection suffices to make the diagnosis of 
jaundice, but to determine its cause is most difficult. If the jaundice 
comes on in the course of a gastro-duodenal catarrh, and there is no 
apparent change in the liver, nor disease of other organs, it is probably 
a case of simple catarrhal jaundice. If it occur in the course of a mala- 
rial fever, it is probably of this form. If the jaundice is preceded by 
sudden violent pain in the right hypochondrium, it is due to the pas- 
sage of gall-stones. If the jaundice be intermittent, but irregularly so, 
and if the attacks occur frequently, the jaundice from one attack not 
disappearing before another comes on, the cause is probably gall-stones. 
If the attacks are regularly intermittent, and accompanied by fever of 
high grade, preceded by a chill and succeeded by a sweat, the cause is 
malarial. If the jaundice be persistent — lasting many months — and in- 
tense, and follow an attack of pain which has not been repeated since, 
the liver remaining unchanged in size, it is probably due to a permanent 
occlusion by a gall-stone. An intense, persistent jaundice, with uni- 
form and painless enlargement of the liver, without other indication 
of disease, may signify obstruction by hydatids. A faint jaundice, a 
mere fawn-color, lasting many months unchanged, with evidence of 
contraction after a period of enlargement of the organ, is produced by 
sclerosis or cirrhosis, or nutmeg-liver, and this diagnosis becomes more 
certain if there be present ascites and enlargement of the superficial 
veins of the abdomen. Jaundice, with persistent pain or soreness in 



COXGESTIOX OF THE LITER. 



169 



the right hvpochondrium and considerable enlargement of the lirer, 
indicates cancer. 

Treatment. — The several conditions of which jaundice may he a 
symptom require treatment according to their nature, and the reader 
is referred to the special articles for the necessary guidance. Irre- 
spectiye of the cause, the treatment of jaundice is concerned with the 
removal of this symptom. As most cases are due to some kind of ob- 
struction, it is improper to stimulate the organ, unable to discharge 
into the intestine that which it has already produced. Laxatives and 
diuretics are the obvious remedies to secure the elimination of the 
biliary matters circulating in the general system. Grain-doses (one 
grain) of calomel, rubbed up in sugar of milk, and given at night, is 
the best laxative in these cases, but this remedy must not be given fre- 
quently, lest ptyalism result. Calomel allays the irritability of the 
gastro-duodenal mucous membrane, lessens the activity of the liver, 
which is shown by the diminution in the amount of bile excreted, and 
stimulates to increased effort the glands of the lower ileum and csecum. 
This combination of actions renders calomel peculiarly serviceable in 
the obstructive forms of jaundice. Experiments on animals and ob- 
servations on a man with a biliary fistula (Westphalen's case*) have 
apparently proved that calomel lessens the flow of bile. Saline laxa- 
tives, which have a diui'etic action, are very useful : they promote 
elimination by the two most important channels. In two instances of 
persistent jaundice from catarrhal obstruction, I have seen very sud- 
den relief afforded by the compound jalap powder, when numerous 
remedies had been given in vain. In jaundice — a malarial complica- 
tion — quinine greatly hastens the cure. \\ hen gouty subjects are 
affected by jaundice, manganese sulphate is highly useful. The ben- 
zoates — of sodium and ammonium — are excellent remedies, both for 
their influence over the local disturbances in the duodenum and over 
the action of the kidneys. 

CONGESTION OF THE LHTER. 

Definition. — By congestion of the liver is meant an increase in the 
amount of blood in the organ. Owing to the mechanical arrangement 
of its vessels, the cii'culation in the liver is influenced by the condition 
of the heart and lungs, by the state of digestion, and by the action of 
the diaphragm and abdominal muscles. It is therefore peculiarly liable 
to suffer from changes in its blood-supply. It may be active (malaria, ex- 
cesses in eating) or passive (mechanical stasis from obstruction at the 
heart or lungs). 

Causes. — The increased fullness of the portal vein and hepatic ar- 
tery during the process of digestion is a physiological state, which 

* " Deut. Archiy fiir klin. Med.," 1873, Band xi. 



170 



DISEASES OF THE LIVER. 



becomes pathological when excesses in eating and drinking are habitu- 
ally committed. The admission of irritating substances to the blood, 
as alcohol, highly stimulating condiments, the salts of lead, phospho- 
rus, etc., increases the tendency to congestion. In malarious regions, 
congestion of the liver is produced and maintained by the absorption 
of malaria, especially when in sufficient quantity to cause febrile at- 
tacks. Without the objective evidence of malarial infection afforded 
by fever, the spleen may greatly enlarge (ague-cake), and the liver be 
kept abnormally full of blood. 

Obstruction and regurgitation of the mitral orifice and of the right 
cavities induce abnormal fullness of the venous system and ischsemia 
of the arteries. After the lungs, the liver is the first organ to suffer 
the passive congestion thus caused. The same result is produced 
when an obstructive disease of the lungs maintains congestion on the 
venous, and ischsemia on the arterial side of the systemic circulation. 

A state of the nervous system may affect the circulation in the 
liver to a great extent : injury of the semi-lunar ganglion causes im- 
mense congestion (Frerichs). Section of splanchnic nerves and the 
action of curare and some other poisons have the same effect. A fit of 
anger has brought on an attack of jaundice. Indeed, the facts prove 
that the nervous system, probably through the vaso-motor nerves, ex- 
ercises an immediate influence over the circulation of the liver, the 
mechanism consisting in an increased or diminished blood-supply, by 
paresis or spasm — by the action of the dilator or constricting fibers 
of this system. Also, the liver possesses considerable elasticity, and 
enlarges and contracts with the increase and the diminution of the vas- 
cular pressure (Brunton).* 

Congestion may also occur in consequence of sudden arrest of an 
habitual discharge, and has followed a successful operation for hsemor- 
rhoids.f 

Pathological Anatomy. — When the congestion is the result of 
mechanical obstruction at the heart or lungs, the changes which are 
entitled " the nutmeg-liver " are seen on section of the organ. At the 
center of each lobule the dilated radicle of the hepatic vein, enlarged 
and congested, may be discerned, while the neighboring parts of the 
lobule are pale, and the radicles of the portal are by comparison less 
full of blood, and really contain less because of the increased pressure 
from dilatation of the central vein. On section, a greater quantity of 
venous blood flows out than is normal, and the whole organ is darker 
and larger. The hepatic cells are either normal or present in places 
some cloudiness from albuminous infiltration, commencing fatty de- 
generation, and some brown-pigment deposition (Forster). The com- 
pression exercised upon the hepatic ducts interferes with the discharge 

* " Lettsomian Lectures " for 1885. 

f Murchison, "Diseases of the Liver," 1877, p. 134. 



CONGESTION OF THE LIYER. 



171 



of bile ; and staining of the lobules about the central vein is a result, 
causing that appearance known as " hepatic icterus." The consistence 
of the liver is augmented by the congestion if it continue for a length- 
ened period. The bile is not changed in its composition (Frerichs), 
A catarrhal state of the ducts is set up as a consequence of the con- 
gestion, and in due course hypersemia of the portal radicles of the 
gastro-intestinal canal takes place, and a catarrh of the mucous mem- 
brane results. 

Long-continued hyperaemia of the liver establishes a slow atrophic 
degeneration of the organ, consisting in wasting and disappearance of 
those cells lying in contact with the dilated central vein, their places 
being supplied by connective tissue having a granular appearance. 
The disappearance of these cells and the contraction of the newly 
formed connective tissue cause a diminution in the size of the liver, 
and an increase of its density, so that this state is often confounded 
with cirrhosis ; but the substance of the organ has not the density, 
nor are there present the prominences which give the nodular aspect 
to the latter. 

Symptoms. — Acute congestion of the liver usually begins with a 
general malaise ; aching in the limbs and back ; some slight rise of 
temperature toward evening ; headache ; a coated, yellowish tongue ; 
loss of appetite, even repugnance to eating ; nausea. 3Iore or less un- 
easiness, usually a feeling of weight and of tension, and tenderness, 
are experienced over the hypochondrium ; lying on the left side causes 
a very unpleasant sensation of weight and dragging ; buttoning of the 
clothing can not be borne ; and the easiest position is recumbent, with 
the decubitus toward the right lateral plane, so that the congested 
organ can be well supported against the ribs. On the other hand, 
many patients seek a different position and can not bear any pressure 
against the hypochondrium. On percussion, the area of hepatic dull- 
ness is enlarged in all directions. In the normal state the upper bor- 
der of the liver is parallel with the lower border of the sixth rib on 
the mammillary line — in ordinary quiet breathing ; on full expiration 
the liver rises on a line parallel to the fifth rib, and on full inspiration 
it falls to the seventh. The lower border of the liver in health cor- 
responds to the inferior margin of the ribs, or extends a finger's 
breadth below. If the liver is enlarged by hypercemia, the hepatic 
dullness will extend across the epigastrium to the left hypochondrium. 
It is highly important to note that the area of dullness does not repre- 
sent the actual size of the organ, for the thin margins do not return a 
dull sound on percussion. Especially will misconception occur on this 
point when the ascending colon is distended with gas. Again, the 
area of hepatic dullness may be greatly enlarged downward by altera- 
tions in the form and shape of the liver, when congenital, produced by 
tight lacing, etc., or displaced downward by effusion in the thorax, tu- 



1Y2 



DISEASES OF THE LIVER 



mors, etc. Altbougli percussion affords the most certain physical evi- 
dence of enlargement of the liver, inspection may afford some assist- 
ance in making a diagnosis, as by the eye an enlargement of the hepatic 
space may be discerned. By palpation, the liver may be felt project- 
ing below the ribs, and its smoothness or nodulation, its density and 
resistance, may be readily determined. By mensuration, the diameter 
of the two sides may be compared, w^hen it will be found, if the con- 
gestion is considerable, and the atrophic change has not occurred, that 
the right is enlarged. A very characteristic symptom in these cases is 
a light grade of jaundice. If there be no recognizable tinting of the 
skin, the sclerotic will be distinctly yellow, and the complexion will 
have the so-called " muddy " aspect. The integument in the cardiac 
liver is somewhat earthy, faintly yellow, or fawn-color, as in various 
cachexise. In the acute congestion due to temperature changes, to 
malarial infection, to excesses in eating and drinking, etc., there is 
usually some gastro-duodenal catarrh, and catarrh of the bile-ducts, 
and consequently an obstacle to the outflow of bile, with more or less 
intense icterus. The urine in every case contains some pigment, and 
varies in tint from pale sherry to a port-wine color, and casts an abun- 
dant deposit of urates with much pigment matter. In the more severe 
cases there is considerable gastric disturbance, and vomiting of bile, 
and large, so-called bilious discharges take place by the bowels. The 
stools, after the ordinary fecal evacuations, consist of a greenish-yel- 
low or brownish matter, semi-fluid or thinner greenish or yellowish 
liquid having the appearance and consistence of stored-up bile. Some- 
times a large quantity of such material is discharged, giving great re- 
lief, the pain, soreness, and heaviness in the side and the headache and 
feverishness disappearing. Such acute cases are due to climatic, mala- 
rial, or dietetic causes. In the cases of congestion due to cardiac dis- 
eases or pulmonary obstruction, the symptoms of hepatic congestion 
come on slowdy ; there occur a gradual tension and weight in the right 
hypochondrium, a slow increase in the size of the liver, an enlargement 
of the area of hepatic dullness, and, usually, a very slight appearance 
of icterus, combined with more or less cyanosis, producing a violet-yel- 
low or greenish coloration. Often, in protracted examples of this form 
of congestion, there exists extensive gastro-intestinal catarrh, with dis- 
turbed digestion, nausea, vomiting, diarrhoea, etc. In those cases of 
congestion of the liver due to psychical impressions, jaundice is the 
main symptom ; there exists really a congestion in biliary production, 
with more or less hypersemia, but there is no marked enlargement, 
tenderness, or heaviness in the hepatic area, and the patients experi- 
ence the sensations belonging to an intense icterus, consisting of itch- 
ing of the surface, depressed spirits, slow action of the heart, muddy 
urine, and a general yellowness or jaundice. 

Course, Duration, and Termination. — The subsequent behavior of 



COXGESTIOX OF THE LITER. 



173 



cases of hepatic congestion offers wider differences than exist in the 
clinical history. The cases of congestion due to obstructive diseases 
of the heart or lungs develop slowly and continue indefinitely, and 
their course and duration are those of the cardiac or pulmonary dis- 
ease. In these cases important alterations occur in the liver ulti- 
mately ; it undergoes atrophy, obstruction to the portal circulation is 
added to the stasis in the general venous system, and ascites slow'ly 
forms. In the acute cases due to climatic and hygienic causes, the 
course is short, but the symptoms are violent. The whole duration 
of such an attack will not be more than a week or ten days, and the 
termination is in health. The same causes which produce the attack 
will operate in the future, and other attacks will succeed, and ulti- 
mately, in some cases, chronic disease of the liver will be established ; 
but, if the causes cease, the effects will also. In the nervous cases, 
the jaundice reaches its maximum in a few hours, and then begins 
to decline, and usually lasts four or five days, terminating in re- 
covery. 

Diagnosis. — The acute form of congestion may be confounded with 
jaundice from catarrh of the bile-ducts, the symptoms being much the 
same ; but the duration of the cases differs, and the latter is preceded by 
symptoms of gastro-duodenal catarrh, while in the former these symp- 
toms succeed to the disturbance in the hepatic functions. The conges- 
tion due to obstructive pulmonary or cardiac disease is diagnosticated 
by its clinical history and the association of the two groups of lesions. 
The contraction of the liver, which succeeds to enlargement in the 
cases of nutmeg-liver, may be confounded with cirrhosis ; but, as these 
states have been confounded by pathologists, the differentiation is not 
important from the clinical standpoint. 

Treatment. — The treatment of the cases due to pulmonary or car- 
diac obstruction is a question of the management of the lesions, cardiac 
or pulmonary, as the case may be. Xot unfrequently, before the heart 
and lungs are incommoded in mitral disease, the hepatic functions are 
so disturbed as to demand attention. The timely prescription of digi- 
talis may afford relief, not given by the remedies for disorder of the 
liver. As the condition is one of abnormal fullness of the venous sys- 
tem of the liver, relief is afforded in those of full habit by leeches 
around the anus. Unfortunately the need for digitalis, to diminish the 
leak at the mitral and for leeches to unload the distended veins, con- 
tinues. Free watery evacuations, produced by salines, are highly use- 
ful ; but in the progress of this disease the congestion of the mucous 
membrane excites a catarrh and diarrhoea, so that the limit of utility 
by saline purgatives is soon reached. In the acute congestion due to 
climatic or malarial causes, no remedy is so efficient as a full dose of 
quinine (grs. xv — 3 j) with morphine (gr. ^ — |-). Small doses frequent- 
ly repeated may, if preferred, be employed, but the large dose is more 



DISEASES OF THE LIVER. 



efficient. A mild saline laxative, to keep the bowels soluble (the Sara- 
toga waters may be used), is necessary, and elimination by the kidneys 
should be maintained by the use of lemonade and diluents. Fomen- 
tations, turpentine-stupes, etc., applied to the hepatic region are ser- 
viceable. When the attacks are due to errors of diet, spirituous liquors, 
and similar abuses, there must be a change in the habits of the indi- 
vidual. Abstinence, the use of a laxative, and quiet, will effect a cure, 
provided the excesses have been recent, and alterations of structure 
have not occurred in the liver. 



INTERSTITIAL HEPATITIS — SCLEROSIS OF THE LIVER— CIR- 
RHOSIS. 

Definition. — By the term interstitial hepatitis is meant an inflam- 
mation of the intervening connective tissue. An induration of the 
organ is the result of this process, and hence it is entitled sclerosis, 
just as this term is used for corresponding states of other organs — as 
sclerosis of the kidney, sclerosis of the lungs, etc. Cirrhosis is the 
French term derived from the Greek word Jcirros (yellow), so named 
on account of the color of the liver ; but it is a very inappropriate 
designation, and should cease to be used. 

Forms. — The ordinary form of cirrhosis, and that to which this 
term is applied, is the contracting, designated the granular liver, be- 
cause of the appearance on section. The nodulated character produced 
by the new-formed connective tissue in contracting, has given to this 
affection the familiar English name, hoh-nailed liver. 

There are some other forms characterized by hyperplasia of the 
connective tissue, and atrophy of the proper gland elements, in which 
no contraction ensues, the organ remaining permanently enlarged. 
To these forms is applied the term hypertrophic cirrhosis. One of 
these is supposed to arise spontaneously ; another succeeds to inflam- 
mation of the ducts, and obstruction caused by hepatic calculi. A 
third form of the hypertrophic is the fatty, the connective tissue un- 
dergoing fatty degeneration without contracting. 

Causes. — This is a disease of adult life, and rarely occurs before the 
period of puberty, chiefly because the conditions are wanting at this 
time. Griffith reports a case in a child of ten ; Cayley, in another 
child of six ; and Murchison, in a boy of ten. Nothing definite as re- 
gards the cause was known in the first two, notwithstanding a search- 
ing investigation ; in the other, the abuse of spirits, medicinally and 
otherwise, was ascertained.* Murchison has never met with an exam- 



* " Transactions of the Pathological Society," vol. xxvii, 1876, pp. 186, 194, 199. 



SCLEROSIS OF THE LITER. 



175 



pie of hob-nailed liver in which excess in the use of spirits had not 
been made out. There can be no doubt that the male sex is more fre- 
quently attacked than the female, not because there exists any inapti- 
tude in the latter, but because of the difference in habits. The great 
factor is the free use of alcoholic liquors. The amount which consti- 
tutes excess differs in different individuals ; in some subjects a small 
amount of alcohol, daily, suffices to set up the interstitial inflamma- 
tion, when another person would not be affected by it in any way. It 
is highly probable that hereditary syphilis is a cause, but there are 
obvious difficulties in the way of a correct determination of this point. 
The form of atrophy which succeeds to the chronic stasis of the liver 
in obstructive cardiac disease is often confounded with sclerosis proper, 
but the change begins by an atrophy of the hepatic cells next the 
intra-lobular vein in the former ; whereas, in the latter, the atrophy 
begins in the peripheral cells. 

Sclerosis has been observed to follow impaction by gall-stones and 
the paludal cachexia. 

Pathological Anatomy. — In the first stage, the organ is somewhat 
increased in size and hypersemic ; its parenchyma is somewhat denser, 
by reason of the presence of a viscid, reddish-gray material, which 
consists of fine connective-tissue elements, containing spindle-shaped 
cells (Forster).* The development of this material imparts to the par- 
enchyma a granular aspect. The color of the organ is at this period a 
brownish-red, whence the name cirrhosis, or it may be greenish by 
staining of the bile -pigment ; or the deposition of fat may give it a 
pallid appearance. Thus far, there is an actual addition of material to 
the organ, and it is somewhat increased in size. The next step con- 
sists in the contraction of the new connective tissue and induration. 
The substance of the liver is distinctly harder, and, on section, the 
knife is resisted as if passing through fibrous tissue. The surface of 
the organ is unequal, nodulated, and traversed by distinct, thickened 
bands of connective tissue (whence the English term "hob-nailed"). 
The line of section presents a granular appearance, due to the contract- 
ing of the intervening connective-tissue elements, and the consequent 
forced elevation of the softer material of the lobules. The peritoneum 
is opaque, thickened by organized exudation, the results of local peri- 
tonitis, and adhesions are formed to the diaphragm, between the liver 
and gall-bladder, etc. The appearance of the hepatic tissue is due to 
a hyperplasia of the connective tissue (Glisson's capsule) surrounding 
and compressing the groups of cells. The cells themselves, where the 
growth of connective tissue is sufficient to compress them, undergo a 
change partly fatty, partly pigmented, and in some places amyloid. 



* Op. cit., p. 264. 



176 



DISEASES OF THE LIVER. 



The abnormal pigmentation is due to compression of the terminal 
ducts and stasis of the bile. The vessels of the liver are variously 
damaged. In those parts where the greatest destruction of cells has 
occurred, thi radicles of the portal vein are obstructed, and the radi- 
cles of the sub-hepatic are also closed by compression and lose their 
connection with the capillaries of the portal. The hepatic artery be- 
comes dilated, and supplies the newly formed vessels of the recently 
developed connective tissue."^ The important alterations occurring in 
the liver lead to secondary disorders of a serious kind. The interrup- 
tion to the circulation by closure and obliteration of many of the he- 
patic capillaries — portal and hepatic — necessarily causes stasis in the 
whole range of the portal system, including the chylopoetic viscera. 
The formation of bile is impaired, diminished, and at many points en- 
tirely suppressed. The glycogenic and urea-forming functions are dis- 
ordered to the same extent ; consequently the depuration of the blood 
and the function of digestion, in so far as the presence of bile is neces- 
sary to the latter, are hindered or prevented. 

HYPERTROPHIC CIRRHOSIS.— In that form of cirrhosis which is 
entitled hypertrophic^ the liver continues enlarged, and may weigh from 
five to eight pounds. It also retains its shape, remains smooth usually, 
but may be marked by small prominences, due to the compression of 
islets of parenchyma by the increasing connective tissue. While, in 
ordinary cirrhosis, the new-formed connective tissue incloses groups 
of lobules, and*is hence designated amiular or multilobular cirrho- 
sis,\ in the hypertrophic form, single lobules are inclosed ; hence the 
term monolohiilar. The initial change in ordinary cirrhosis begins in 
the connective tissue about the interlobular vein ; in hypertrophic 
cirrhosis, about the interlobular duct. In the latter, processes of con- 
nective tissue, enlarging, project into the lobule, separating the rows 
of hepatic cells composing it, and these undergo atrophy. Broad bands 
of connective tissue newly formed extend through the organ between 
the parenchyma islets. 

As with these changes in the connective tissue, inflammation of the 
interlobular ducts ensues, with this form of cirrhosis there is more 
or less jaundice, and hence it has been entitled " biliary cirrhosis. " 
The spleen also enlarges considerably by simple hypertrophy. The 
other changes in related organs are the same as those of ordinary 
cirrhosis. 

* Cornil, " Note sur I'etat anatomique des canaux biliaires et des vaisseaxix san- 
guins dans la cirrhose du foie," " Bull, de I'Acad. de Med.," " Gaz. Med. de Paris," 
1873. 

t Charcot and Gombault, " Archiv. de Physiol. Normal et Pathol," ISTG, p. 453 et seq. 
Also, Charcot, " Le9ons sur les Maladies du Foie," etc. 



HYPERTROPHIC CIRRHOSIS. 177 

Symptoms. — The initial symptoms are those of congestion — some 
heaviness, and dragging in the right side, and increase in volume, the 
liver projecting a finger's breadth below the ribs. There will be pres- 
ent, usually, some pain and tenderness on pressure, and now and then 
acute pain with a febrile movement indicative of local peritonitis. A 
slight icterode hue of the skin may also appear, and rarely jaundice. 
Again, in other cases, before symptoms referable to the liver mani- 
fest themselves, gastro-intestinal disorders — gastro-intestinal catarrh — 
occur. The appetite is poor, and food occasions distress ; there is 
acidity, and acid matters are regurgitated ; often in the morning there 
are much nausea and great straining, some acid, glairy mucus and bil- 
ious matter coming up after much effort. The bowels are sometimes 
relaxed, sometimes constipated, and now and then blackish, tar-like, 
semi-solid discharges occur. As intestinal hypersemia is always pres- 
ent, and sero-mucus constantly poured out, diarrhoea soon comes to be 
the usual condition. A troublesome meteorism is a constant symptom, 
and this is due to decomposition of certain foods and a paretic state 
of the bowels. There are also cases, but rarely, in which the devel- 
opment of sclerosis takes place silently, and the first symptom to 
awaken attention is ascites. As respects size, the liver usually enlarges 
at first, but contraction soon comes on, and a considerable reduction 
takes place, the area of hepatic dullness being correspondingly reduced, 
except in that form, of the disease known as hypertrophic cirrhosis, in 
which the dullness on percussion increases in all the diameters, or at least 
does not diminish. As the splenic forms a part of the portal system of 
veins, a constant stasis is maintained in the circulation of the spleen, 
and hence this organ remains swollen ; but there are variations in its 
size, due to the formation of a collateral circulation, and occasionally 
to the development of a sclerosis in the organ. A constant stasis 
is also maintained in the intestinal mucous membrane, with the re- 
sults already mentioned. An attempt at compensation for the ob- 
struction in the venous system of the abdomen is made by enlarge- 
ment of certain communicating veins, which in health are but slightly 
auxiliary to the regular route of communication. On the surface 
of the abdomen, from the xiphoid appendix to the pubis, veins ap- 
pear, which were previously invisible ; they are the communicating 
veinules between the epigastric and internal mammary, forming 
an irregular, feather-shaped figure ; interlacing vessels also develop 
along the rectus muscle, laterally ; communication is established be- 
tween the parietal veins and the accessory vena porta of Sappey, 
and those branches of this accessory portal, communicating with 
the epigastric and internal mammary veins, form a cushion, bluish 
in color, of distended vessels around the umbilicus (caput Medusae) : 
communication also takes place between the inferior mesenteric 
14 



178 



DISEASES OF THE LIVER. 



and the hypogastric veins, through the hsemorrhoidal, and between 
the anastomoses of the portal with the oesophageal and diaphrag- 
matic veins. 

Haemorrhages result from the stasis — hgematemesis or vomiting of 
blood, and intestinal haemorrhage ; the vessels yield under the in- 
creased pressure ; or thromboses form in the stomach-veins, solution 
of the affected mucous membrane occurs, and an ulcer is the result. 
The author has seen two cases of cirrhosis in which frequently recur- 
ring hsematemesis caused death, the haemorrhage coming from small 
ulcers in the vicinity of the pylorus. The black, tar-like stools which 
are passed now and then in contracted liver consist of blood altered 
by the intestinal juices. The same obstruction of the portal circula- 
tion leads to the formation of haemorrhoids, which often bleed freely 
and thus afford relief. Besides the interference with the digestive 
function due to the gastro -intestinal catarrh, the solution and absorp- 
tion of certain kinds of food are prevented by the absence of the bile. 
These are especially the fatty and saccharine matters, and bile has the 
peculiar property of aiding the absorption of fats. Further, it plays 
the part of an antiseptic agent, and prevents the decomposition of food 
in the small intestine : when bile is absent the faeces are not only want- 
ing in the proper color, but they have a peculiarly fetid odor — the odor 
of decomposition — and the gas passed has the same foul smell. A 
gradual emaciation is the necessary result of this morbid condition of 
the intestinal digestion. The integument of the face, neck, and fore- 
arms acquires a peculiar, earthy, icteroid hue, but a real jaundice is 
not common in cases of sclerosis. Sometimes with the first conges- 
tion, which initiates the morbid process, jaundice is a symptom, but it 
soon disappears and the earthy, fawn color, so characteristic in these 
cases, gradually develops. In those cases of sclerosis succeeding to 
impaction by gall-stones, jaundice has been a prominent symptom. 
When the cells have atrophied, and the canaliculi are obliterated, re- 
sorption of bile is no longer possible. The very considerable inter- 
ference with the process of digestion produced by sclerosis and the 
retention in the blood of those effete materials which it is the func- 
tion of the liver to remove induce an unhealthy condition of that 
fluid, and hence venous stigmata appear on the face and nose, and 
bleeding occurs from the nose, lungs, peritoneum (peritonitis ha^mor- 
rhagica), and elsewhere.* The urine is small in quantity, high colored, 
brownish, deficient in urea, but loaded with urates which are deposited 
in great abundance along with much coloring matter. CEdema of the 
feet and ankles succeeds to ascites, and the genitalia become much 
swollen. But the clinical history and treatment of ascites have been 
sufficiently discussed. 



"These de Paris," 1874, Azmi Ahmed, " Des hemonhagies dans la cirrhose." 



SCLEROSIS OF THE LIVER. 



179 



Course, Duration, and Termination. — The course of interstitial hepa- 
titis is essentially chronic. The first stage, or period of congestion and 
enlargement, often escapes notice, and only the stage of contraction, 
with its accompanying derangements, comes under observation. The 
duration is not fixed, and the termination is governed by the extent 
of the contraction and the consequent interference with function, 
but especially by the existence or appearance of such complications as 
mitral disease, emphysema of the lungs, and chronic interstitial nephri- 
tis. Fibroid change, such as occurs in sclerosis of the liver, may mani- 
fest itself simultaneously in other organs, as fibroid lung, fibroid heart, 
fibroid kidney. Obviously, the course and duration of the hepatic dis- 
ease will be much influenced by the coexistence of this form of degen- 
eration in other organs. Toward the end of some cases, brain symp- 
toms arise which were at one time supposed to have the same relation 
to retention of effete products removed by the liver in the normal con- 
dition as the cerebral sym^^toms in albuminuria had to the failure of 
kidney excretion. By Flint this toxic material is supposed to be cho- 
lesterine, and hence the term cholestersemia which he applies to these 
cerebral symptoms. This condition of the brain takes the form of 
stupor, and low-muttering delirium, passing into deep coma. In a few 
cases sopor and gradually deepening stupor come on early. These 
mental symptoms are, however, mixed up with the perturbation due 
to alcoholic excess, so that it is impossible to assign to each factor its 
proper influence in the development of this state. A large proportion 
of cases end before these mental symptoms are reached, cut off by in- 
tercurrent maladies, such as pleuritis, pericarditis, pneumonia, etc., or 
die exhausted by haemorrhage. Some cases proceed to a typical end- 
ing by gradual failure, worn out by the diflicult breathing from exces- 
sive accumulation of fluid, the constant upright position, the ulcerated 
legs, the bleeding haemorrhoids, repeated tapping, stupor, delirium, 
and gradually deepening coma. 

Diagnosis. — When all the usual symptoms of sclerosis are present, 
and the subject of them has been given to alcoholic intoxication, there 
can be no difficulty in coming to a diagnosis by exclusion. Further- 
more, sclerosis is greatly more frequent than any of the diseases with 
which it may be confounded. The difficulties of differentiation occur 
with pylephlebitis, fatty liver, hydatid cysts, cancer or tuberculosis of 
the peritoneum. In pylephlebitis or inflammation with thrombosis of 
the portal vein, there may be present the same symptoms as in sclero- 
sis, but they arise suddenly, and are not preceded by the symptoms of 
congestion and a history of alcoholic abuse. Fatty liver is one of the 
complications of phthisis, and also occurs in the obese, or in those hav- 
ing the tendency to obesity and who eat and drink freely and lead sed- 
entary lives. Although the symptoms referable to the liver are similar 
to those which are present in sclerosis, there are important points of 



180 



DISEASES OF THE LIVER. 



difference. In fatty liver emaciation is wanting ; the organ is enlarged 
and smooth, instead of being contracted and nodulated. In hydatid 
cyst, there is a slow, gradual, and painless enlargement, with but little 
interference in the function of the liver, and without the secondary gaS' 
tro-intestinal disorders. On palpation, a large, soft, elastic growth can 
be made out, and having that peculiar symptom, the "purring tre- 
mor." These symptoms are all wanting in sclerosis. Cancer differs 
from sclerosis in that the pain is greater, the wasting more rapid, the 
liver presents large protuberances, and secondary deposits in the mes- 
entery can be felt in advanced cases. Cancer and tubercle of the peri- 
toneum are accompanied by symptoms much like sclerosis. They may 
be differentiated by attention to the following points : In sclerosis, 
there is enlarged spleen ; the urine is deficient in urea but contains leu- 
cin and tyrosin, and casts an abundant deposit of urates and coloring 
matter ; in cancer or tubercle, the spleen is not enlarged ; the urine 
contains its proper proportion of urea, and is pale and watery. In can- 
cer or tubercle of the peritoneum, there is great tenderness of the 
abdomen ; the ascites develops quickly ; the strength and flesh rapidly 
decline, and there are usually cancer or tubercle deposits in other 
organs. 

Prognosis. — The course of sclerosis is usually continuously down- 
ward, and hence the prognosis is unfavorable. The author believes 
that the opinions as to its incurability, based on experience, must be 
somewhat modified now, in view of the results of modern treatment. 

Treatment. — At the outset the author must condemn the use of 
mercurials given with a view to correct the hepatic secretions. The 
secretory function is disturbed, because the liver-cells have atrophied 
and the ducts are closed. When this result is reached, no treatment 
can modify the case, for remedies can not restore lost parts. Before 
important changes have occurred, although new connective tissue has 
formed, and some contraction has taken place, the author believes that 
much may be done to arrest the morbid process. There is a group of 
remedies which have a selective action on the liver, the metals chiefly: 
gold, silver, copper, arsenic, mercury, and phosphorus, which have the 
property of improving the nutrition of the liver if used in a small 
quantity for a long period. The most eflicient of these are the chlorides 
of gold and sodium, the corrosive chloride of mercury. Fowler's solu- 
tion, and phosphorus in the form of phosphites or phosphates. When 
there is much irritability of the gastro-intestinal mucous membrane, two 
drops of Fowler's solution, with two to five drops of opium tincture, 
three times a day, will be most easily borne. If there is less irritability, 
the chloride of gold and sodium (gVA corrosive chloride of 

mercury (^V-gV ^'^^ ^^'^j ^® administered. No good result 

should be expected unless the remedies are kept up for several months. 
The author has seen surprising results by the long-continued use of 



ABSCESS OF THE LIVER. 



181 



sodium phosphate in these cases — given in 3 j— 3 j doses three times 
a day. The good effects of both remedies may be obtained by joint 
administration — the phosphate in solution, the chloride in pill form. 
When it is considered desirable to give phosphates and arsenic to- 
gether, phosphate of soda and arseniate of soda may be combined. If 
there is a suspicion of syphilitic taint, the iodides of potassium and 
ammonium and the bichloride of mercury are the appropriate medica- 
ments. The mineral acids, which at one time were supposed to be effi- 
cacious in the treatment of this hepatic disorder, are now rarely em- 
ployed, except to facilitate digestion. The nitro-muriatic bath is a 
serviceable topical application, especially the general bath, to improve 
the condition of the skin, which is dry, harsh, and scurfy. Attention 
to the diet is of the first consequence. Fats and saccharine foods, not 
undergoing solution and absorption, decompose and add to the existing 
mischief. The continued use of skimmed milk freely is a dietectic 
measure of the highest importance. Those components of a diet con- 
vertible into peptones should be directed, and the most easily digest- 
ed substances only. When ascites forms, it must be treated according 
to the principles already set forth under that head ; the activity of the 
kidneys must be maintained, and puncture practiced according to ne- 
cessity. 

LOCAL PARENCHYMATOUS HEPATITIS— SUPPURATIVE HEPA- 
TITIS—ABSCESS OF THE LIVER. 

Definition. — The hepatitis which terminates in suppuration is local- 
ized to a special part, and the rest of the organ, outside the area of 
suppuration, continues comparatively normal. It is a parenchymatous 
inflammation in that the proper structure of the organ — the gland-cells — 
is the seat of the inflammatory process. It is a suppurative hepatitis, 
in that the tendency is to the formation of matter, and the resulting ab- 
scess is the special feature demanding attention. Murchison makes an 
appreciative distinction between pysemic and tropical abscesses — the 
former, a result of blood-poisoning ; the latter, caused by inflamma- 
tion of the liver. It is the latter form which is intended by the term 
suppurative hepatitis, but the post-mortem changes and the clinical his- 
tory, so far as the liver itself is concerned, are the same in the two forms. 

Causes. — External injury but rarely excites suppurative inflamma- 
tion, and a blow on the right hypochondrium will more frequently 
cause an inflammation of the hepatic peritoneum than of the hepatic 
substance. Blows are more apt to cause abscess of the liver in warm 
than in cold countries. Climate is one of the principal factors.* A 
warm climate, an alluvial soil, and miasmatic influences, are more influ- 

* Sachs, " Ueber die Hepatitis der heissen Lander," Berlin, 1876. Separat-Abdnick 
aus von Langenbeck's " Archiv," Band xix. 



182 



DISEASES OF THE LIVER. 



ential in combination than climate alone. Abscess of the liver is very 
common in the great interior valley of North America — along the 
Mississippi and its tributaries, within the malarial area — as it is in 
India, and because of the same etiologic and climatic conditions. 
Y/ithout producing the objective phenomena of fever, malaria dis- 
turbs the hepatic functions, but the disturbance is still more decided 
when the poison is intense enough to cause fever. Dysentery and 
ulceration of the intestines have so frequently coincided in appearance 
with, or have preceded, abscess of the liver, that a causal relation is sup- 
posed by many to exist between them. In the interior valley of this 
continent, at Cincinnati, the author saw many cases which had succeeded 
to attacks of malarial fever, and to dysentery— -especially proctitis — the 
lesions of which are situated chiefly or wholly in the rectum. Fre- 
richs,* Murchison,f and some other systematic writers, after a thorougli 
examination, maintain the opposite view, that the supposed relation be- 
tween abscess of the liver and dysentery is merely coincident, and is not 
causal. Waring's | statistics seem quite conclusive against the view that 
such a relation exists : thus, " out of 2,758 cases of dysentery treated 
in the Madras Presidency, abscess of the liver occurred 68 times, being 
in the proportion of 2^ per cent, nearly." In the same author's 300 
cases of abscess of the liver, "hepatitis was the primary affection in 
131, or 43 per cent., while only 82, or 27 per cent., were admissions 
from dysentery." Budd § holds that a poison generated in the intestine 
by the decomposition of materials from ulcerations is the chief factor 
in the causation of abscess. Moxon || also maintains that " almost all 
tropical abscesses are secondary to dysenteric or other ulcerations, and 
that primary abscess of the liver is at least as doubtful as primary 
suppuration of the brain." The concurrence of hepatic abscess and 
dysentery is too frequent not to be related in some way ; it is clear 
that many, but probably not a majority, of the cases thus originate, 
and, when so caused, the abscesses are pysemic, multiple, and secondary. 
Large abscesses of this kind are due to the coalescence of neighboring 
smaller ones. A very intimate causal relation exists between ulcera- 
tion of the caecum or of the appendix vermiformis and abscess of the 
liver, numerous cases of the kind having been reported.^ A large 
number are doubtless due to hepatitis — the so-called tropical abscesses. 
A variety of causes are concerned in the production of others. The 
habits of individuals are not without influence, especially the use of 

* " Diseases of the Liver." Translated by Murchison. Syd. Soc, vol. ii, p. 108. 

f "Clinical Lectures on Diseases of the Liver," etc. Second edition, p. 177. 

X *' An Enquiry into the Statistics and Pathology of Some Points connected with Ab- 
scess of the Liver, as met with in the East Indies." By Edward John Waring. Trevan- 
drum, 1854. 

§ *' On the Diseases of the Liver," p. 83, et seq. 

Ij " Transactions of the Pathological Society of London," vol. xxiv, p. 116, 1873. 
^ Ibid., various volumes. 



ABSCESS OF THE LITER. 



183 



stimulants, highly seasoned dishes, condiments, etc. Suppuration has 
been caused by the impaction of calculi, by the lodgment of a lumbri- 
coid worm, etc. It is a more common malady in men than in women, 
and from the twentieth to the thirty-fifth year. A case is reported by 
Grainger-Stewart, in which abscess of the liver followed dilatation of 
the bile-ducts.* 

Pathological Anatomy. — That a certain proportion of cases of he- 
patic abscess are due to embolic deposits, coincident ulcerations exist- 
ing in the intestine, is probably true, but the facts of observation which 
support this theory are surprisingly few. Frerichs f reports one of em- 
bolic blocking of a vessel at the site of a commencing abscess, and a 
few others have been recorded. Forster J holds that a miasmatic infec- 
tion of the blood is caused by the ulceration in the intestine. Whether 
it be due to such infection, or to the formation of a thrombus and sub- 
sequent embolic blocking of a veinule of the liver, or to hepatitis, or 
to any other cause, the initial lesion is a hypersemia of the hepatic cells 
at the site of the abscess. The cells become cloudy and granular by 
the presence of an albuminous matter deposited in them. Liebermeister 
maintains, but he is alone in this opinion, that the initial change is in 
the connective tissue ; but Rokitansky, Yirchow, Frerichs, Forster, and 
others, refer the first changes to the cells of the hepatic parenchyma, 
and the alterations in the connective tissue to a subsequent period. 

Those parts of the hepatic parenchyma in which the liver-cells are 
undergoing disintegration, at first have a reddish-yellow appearance, 
and at some points contain patches of pigment of a bright yellow 
color, and are surrounded by a translucent pale-gray ring. The acini, 
the seat of this process, are distinctly enlarged, become softer, and 
disintegrate. The center of each inflamed patch early becomes yel- 
low, which indicates the beginning of suppuration. The size of these 
points of suppuration is at first small, but those in close proximity 
coalesce, forming an abscess — a purulent collection. These abscesses 
are filled with pale-yellow pus, and the borders of the collection con- 
sist of dark-red, disintegrating gland-tissue, projecting in the form of 
softening shreds into the purulent depot. They vary in size from a 
pea to a hen's egg, or may attain much larger dimensions. Important 
changes take place in these purulent collections as they grow older : 
the walls become smooth, and are lined by connective tissue, the pus 
thus becoming encysted, or absorption occurs, the walls of the abscess 
approximate, unite, and ultimately nothing remains but a linear cica- 
trix. So perfectly does repair go on and is completed, that in some 
years afterward scarcely a trace of the original mischief can be de- 
tected. In other cases no limiting membrane is produced, the inflam- 

* T. Grainger-Stewart, "The Edinburgh Medical Journal," January, 1873. 
f " Diseases of the Liver," op. eit 

X " Lehrbuch der pathologischen Anatomie von Dr. August Forster." By Dr. Siebert. 
Jena, 1873, p. 267. 



184: 



DISEASES OF THE LIVER. 



mation extends, and an enormous purulent collection, which tends to 
external discharge in some direction, is formed, and enlarges by con- 
tinual accessions of purulent matter. It does not often happen that 
such a collection bursts into the peritoneal cavity, exciting fatal peri- 
tonitis, but it tends to perforate the abdominal wall, or dissects down- 
ward along the spine, discharging in the inguinal region or by the sa- 
crum posteriorly, or it ulcerates through into the stomach, duodenum, 
or colon, or makes its way upward, perforates the diaphragm, the 
lungs, and is discharged through the bronchi. These abscesses have 
also entered the vena cava (case of Colin*), have ulcerated into the 
pericardium, etc., but such accidents are comparatively rare. 

The size of an abscess of the liver varies from an ounce or two to a 
gallon. In 69 cases in which this point was noted, 16 contained one 
to two pints, and 12 two to three pints ; and these may be regarded 
as of the usual sizes. As respects limitation by a neo-membrane, the 
cases are not numerous in which definite statements are made ; in 53 
the abscesses were encysted in 36 and not limited in 17, but it is 
doubtful if this relation exists throughout a large number of unse- 
lected cases. Of Waring's 300 cases, 169, or somewhat more than one 
half, remained intact ; of the remainder, much the largest number of 
the spontaneous discharges occurred by the thoracic cavity — 42 — and 
of these 28 occurred through the right lung. As respects the lobe of 
the liver, which is usually the seat of the abscess, the statistics of vari- 
ous observers agree. Selecting Waring's 300 cases for exemplification, 
we find that the purulent collection was in the right lobe, alone, in 
163, and in both right and left in 35. The number of abscesses present 
at the same time is influenced greatly by the cause ; in the pysemic, 
there may be a dozen or more ; in the other form, from one to three 
usually. Although fetid decomposition is not uncommon,! yet true 
gangrene is very rare. 

Symptoms. — Notwithstanding the importance of the organ, abscess 
of the liver of considerable size may exist without there being any 
local or systemic symptoms to indicate its presence. These latent 
cases occur in the course of chronic dysentery and pyaemia, and fail of 
recognition because masked by existing symptoms, or they are latent 
because the inflammation occurred in the deepest part of the right lobe, 
and did not involve the peritoneum, nor did the abscess compress the 
bile-ducts, and was limited by a neo-membrane. A typical case fol- 
lowing a recognized injury, or due to impaction of calculi, will present 
characteristic symptoms, and the diagnosis will be easy, but many 
other cases may not only be diflficult of recognition, but in some a 
diagnosis will not be possible. 

The onset is marked by the phenomena which attend an inflamma- 

* "Gazette Hebdomadaire de Med, et de Chir.," No. 33, 18'72. 
t Rigal, "L'Union Med.,'» No. 134, 1873. 



ABSCESS OF THE LIVER. 



185 



tory affection ; a chill, or chilliness, aching of the back and limbs, head- 
ache, a dry skin, a coated tongue, bilious vomiting, increased action of 
the heart, a rise in the arterial tension, are the systemic symptoms. 
Locally, there is a feeling of uneasiness, constriction, weight, dragging, 
and often considerable pain and tenderness, especially if the hepatic 
peritoneum is involved. In some cases a pain is felt in the top of 
the shoulder — a tensive pain — and it is experienced in the right shoul- 
der when the right lobe is affected, and in the left shoulder if the 
left lobe is the seat of mischief, and in some cases in both simultane- 
ously. Its value as a symptom is not great, for it is present in other 
hepatic diseases, and may be a merely rheumatic or neuralgic pain. 
On palpation and mensuration, an increase in the size and density 
of the liver can usually, but not invariably, be made out. The area of 
hepatic dullness is increased in all directions, and may be considerably 
so if the purulent collection is a large one. Pushing up the diaphragm 
and displacing the lung, the area of dullness and the absence of voice 
and breath sounds may extend up to the fourth, to even the lower 
margin of the third rib, and downward several finger-breadths below 
the margin of the false ribs, furnishing all the signs of hydropneumo- 
thorax.* Jaundice is present in less than one third of the cases, and 
then varies much in intensity, but it is general, and the urine is loaded 
with bile-pigment, and, when the liver is much damaged, contains leucin 
and tyrosin instead of urea. Jaundice appears early in those cases of ab- 
scess due to the impaction of calculi — soon after or with the initial symp- 
toms, which are those of hepatic colic — and much later in those which 
are the usual cases, due to the pressure, on the hepatic duct, of the ab- 
scess. When pus forms there is usually a decided rigor, and these shiv- 
erings recur irregularly, and are followed by fever and sweats. Like 
the other characteristic symptoms, these are often entirely absent. The 
fever, chills, and sweats are much more pronounced in the so-called 
pysemic abscesses than in those arising from hepatitis. The irritability 
of the stomach is enhanced by the occurrence of suppuration ; the fre- 
quency and persistence of the vomiting at this period is an important 
indication, much insisted on by Maclean f and Fayrer.]; The vomiting 
may have the bilious character, with a large evacuation of bile, and the 
alvine dejections may have the same character ; the vomit may consist 
of watery mucus, and, rarely, of blood. There will be an increase of 
the dysenteric symptoms, if this disease had been in existence when 
the abscess formed, or diarrhoea or dysentery may occur when suppura- 
tion takes place. The size of the liver lessens somewhat, and the area 
of hepatic dullness diminishes when pus forms, if the abscess be in- 

* Ptigal, "L'Union Med.," No. 134, 18lS. 

f " The Diagnostic Value of Uncontrollable Vomiting." Dr. W. C. Maclean, " British 
Medical Journal," August 1, 1873. 

t Sir Joseph Fayrer, ibid., September 26, ISVS. 



186 



DISEASES OF THE LIVER. 



closed ; but, if no limiting membrane is formed, the dimensions of 
the* organ gradually enlarge. The diminution in size is maintained, 
and a gradual return to the normal is the rule, when the pus is ab- 
sorbed and the eavity cicatrizes. Fluctuation is felt and can be de- 
tected only when the purulent collection attains to great dimensions. 
If the abscess tends to spontaneous recovery by absorption, or after 
discharge of pus, the local pain and tenderness subside, the pulse falls 
to the normal, the stomach is no longer irritable, appetite returns, and 
digestion is resumed. If, however, the abscess enlarges, the distress in 
the hepatic region and the tenderness increase ; movements, especially 
of breathing and coughing, awaken deep-seated soreness and pain ; 
breathing becomes difficult by pressure on the lungs ; the heart is some- 
times displaced upward and to the left, which adds to the existing 
praecordial uneasiness and to the difficulty of breathing ; and a harass- 
ing and painful short, dry cough, induced by irritation of the pneu- 
mogastric and phrenic nerve-filaments, adds greatly to the distress. 
As a tendency to discharge through the right lung exists in a large 
proportion of cases, the base of this lung and the neighboring pleura 
are affected by a localized pleuro-pneumonic process, with the usual 
physical and rational signs of that complication. Adhesion of the 
pleural surfaces takes place, and a channel is formed communicating 
with a bronchus, through which discharge occurs. Less often a sec- 
ondary suppurating cavity is constructed by the pleural adhesions. 
Rarely the pericardium is opened, and death caused by sudden disten- 
tion of the sac with pus. If rupture takes place into the peritoneal 
cavity, this untoward accident is announced by sudden, intense pain 
and collapse ; if into the intestine, purulent and bloody evacuations 
indicate it, while lessened size of the liver and less tension and pain 
also coincide ; if the pus dissects outwardly through the hypochon- 
drium, a large, puffy, and fluctuating tumor forms. 

The variations in the symptoms of hepatic abscess are very re- 
markable. There may be no local symptoms — no pain, no tenderness, 
no enlargement. When the purulent collection tends downward below 
the ribs, there may be fluctuation, and when it has attained to great 
dimensions ; but it is a comparatively rare symptom. In much the 
largest number of cases, the pus forms in the upper and superior part 
of the right lobe, in a situation where fluctuation can not be developed. 
Pain may be entirely absent : in Waring's 300 cases of hepatic abscess, 
pain was not present in 20. The reflex shoulder-pain is much less con- 
stantly experienced ; it is more frequently wanting than it is felt. 
Gastric derangement of any kind may not exist, and the patient may 
have a good appetite. The importance of severe vomiting as a symp- 
tom of suppuration is not impaired by the fact that exceptional cases 
are encountered, but vomiting and severe and uncontrollable vomiting 
are highly significant, andvery rarelyabsent. Vomiting is increased by 



ABSCESS OF THE LIVER. 



187 



extension of disease to the peritoneum, and by pressure of an enlarging 
abscess directly upon the stomach. Although the bowels may be'un- 
disturbed in exceptional cases, dysentery is present in a considerable 
proportion — according to Waring, in 82 in 300 cases — but dysentery 
sometimes succeeds to the abscess, and is apparently caused by it. As- 
cites occasionally occurs when the ^bscess compresses the portal, and 
jaundice usually accompanies it, for the common or hepatic duct is en- 
croached on at the same time. 

Course, Duration, and Termination.— So much obscurity exists in 
regard to the initial symptoms, so much variation in the behavior of 
cases, that no defined course can be laid down. The duration is equally 
uncertain and irregular. A typical case without complication may pass 
through its several stages in about seventy days if the pus is discharged 
by a favorable channel; if the pus undergoes absorption, and the cavity 
closes by cicatrization, several weeks longer will be necessary. The 
initial symptoms will occupy less than a week, for suppuration appears 
in a short time after the hypersemia, and the breaking down of the he- 
patic tissue proceeds rapidly, so that an abscess of considerable size will 
form in seven to ten days. Then comes on a period of septicsemic fever 
— remittent in type, with irregular sweats, in the acute cases with ab- 
scess of large size, and intermittent with long periods of freedom from 
fever in the subacute and chronic cases, with abscess of moderate size. 
The course of abscess of the liver is much affected by the development 
of a limiting neo-membrane. When this membrane is formed, if no 
complications are present, there may be a "latent period" of consider- 
able duration — a period characterized by the absence of local and sys- 
temic symptoms. This quiescent state may continue several wxeks, 
months even ; then acute symptoms arise, which are often misinter- 
preted, and supposed to be the initial symj^toms, and the abscess formed, 
the product of the recent disturbance. If, on the other hand, there is 
no limiting membrane formed, and the suppuration extends, the septi- 
csBmic fever persists, and the patient sinks into a typhoid state, with 
low-muttering delirium, and death from exhaustion. 

Cases of acute abscess without complication, discharging in a favor- 
able direction, recover with considerable promptitude. Early and suc- 
cessful use of the aspirator for the evacuation of pus shortens the du- 
ration of a case materially. Convalescence is very tedious when fistulous 
communication exists through the lungs, the parietes of the abdomen, 
and elsewhere. The author has met a case of fistula of the right hy- 
pochondrium discharging somewhat after eighteen months. During 
the existence of such purulent formation and discharge, night-sweats, 
diarrhoea or dysentery, a poor appetite, and feeble digestion combine 
to maintain a condition of debility for a long time, or there may be a 
continuous, gradual failure, terminating in exhaustion and death. In 
the acute cases which terminate fatally there are usually intense hectic. 



188 



DISEASES OF THE LIVER. 



profuse sweats, uncontrollable vomiting, and rapid failure of the vital 
powers. The cases associated with dysentery are very protracted and 
very fatal ; they rarely cicatrize, and less frequently discharge exter- 
nally than do the uncomplicated cases (Frerichs). The condition of 
patients who recover is not always that of health. Very often the in- 
testinal digestion is impaired because of the insufficient supply of bile, 
and the functions of the stomach and intestines are interfered with by 
adhesions and contracting bands of lymph which limit the movements 
of these organs and narrow their capacity, or obstruct the passage of 
their contents. 

Prognosis. — How favorable soever may be the apparent condition 
in any case of hepatic abscess, the prognosis must be guarded, for un- 
expected complications may arise, and the known dangers are uncer- 
tain in their behavior. The pyjemic abscesses are more numerous, are 
due to a poisoned state of the blood, and are always fatal. The direc- 
tion taken by the abscess is an important element in coming to a con- 
clusion ; discharge by the lungs is most favorable ; by the external in- 
tegument the next, and by the intestinal canal, third. Early evacua- 
tion by the aspirator lessens materially the dangers and must enter 
into the question of prognosis. In eighty-one cases of hepatic abscess 
evacuated by operation, collected by Waring, there were fifteen recov- 
eries — 18 "5 per cent. In McConnell's,* fourteen cases in which the 
aspirator was used, six died and eight recovered — fifty-seven per cent. 
Both sets of statistics were gathered in India, but the former were 
cases which occurred before 1850, and the latter since the aspirator 
came into use. Of twenty-five cases of recovery without interference, 
also by Waring, there were ten in which the matter was discharged 
through the lungs, and seven by stool. The size of the abscess, its 
position, the condition of the patient in respect to digestion and nutri- 
tion, and especially the presence or absence of complications, are ele- 
ments which must be taken into consideration in coming to conclu- 
sions. 

Diagnosis. — Hepatic abscess may be confounded with echinococcus 
of the liver, dropsy of the gall-bladder, scirrhus, abscess of the ab- 
dominal wall, effusions, especially purulent, into the right thoracic 
cavity, etc. 

A tumor or enlargement formed by echinococci is unaccompanied 
by pain or tenderness, the growth is slow and without constitutional 
disturbance, when palpated is elastic, fluctuating, and furnishes that 
most characteristic sensation, "the purring tremor." An abscess of 
such a size would be accompanied by pain, tenderness on pressure, by 
septicaemic fever, at least frequently ; there would be wasting and 
diarrhoea, often severe vomiting, and the sense of fluctuation would 

* Remarks on pneumatic aspiration with cases of abscess of the liver treated by this 
method. "Indian Annals of Medical Science," July, 1872. 



ABSCESS OF THE LITER. 



189 



be free from purring tremor. The very important aid to diagnosis 
afforded by the exploring trocar should not be neglected, and its indi- 
cations may indeed be decisive. The fluid of an abscess is purulent, 
and, if hepatic, contains portions of the tissue of the liver ; * if of a 
hydatid cyst, a straw-colored, serous fluid, containing the character- 
istic echinococcus booklets. An enlarged gall-bladder is a pyriform 
tumor of variable size, elastic and fluctuating when its contents are 
fluid, or hard and nodular when enlarged by calculi. When the ac- 
cumulation is a product of the metamorphosis of bile and mucus, the 
growth is very slow, and the symptoms 7iil — a very different history 
from that of abscess ; on the other hand, a purulent fluid forming, will 
be accompanied by hectic, sweats, emaciation, etc., and a differentia- 
tion is not possible. In cases of this kind there has been a history of 
attacks of hepatic colic ; the last one having determined the series by 
a closure of the cystic duct. Abscesses of the abdominal wall of large 
size, and situated in the right hypochondrium, may be very confusing, 
but the distinction may be made by the history, which does not in- 
clude any disturbance in the hej)atic functions, and has not been pre- 
ceded by any symptoms of disease of any kind. The history begins 
with the formation of a tumor in the hypochondrium. The most cer- 
tain means of diagnosticating consists in the microscopic examination 
of the purulent matter, and in determining by the passage of the aspi- 
rator needle that the pus is contained in an abscess exterior to the ribs. 
It is impossible to decide between an hepatic abscess and an abscess 
formed between the hepatic and parietal peritoneum, which may be 
the result of a local peritonitis, or of an hydatid cyst undergoing de- 
struction by suppuration. Multiple abscess of the liver has been mis- 
taken for cancer of the stomach. f The pain, vomiting, wasting, may 
mislead, but the marked difference in the history of the two affec- 
tions, as well as the local symptoms, ought to prevent such an error. 
The most difficult problem in the diagnosis of hepatic abscess is the 
distinction between abscess and empyema, or hydrothorax. Besides 
the evidence of the accumulation of fluid filling in the space from the 
diaphragm to the fourth, even to the third rib, there are almost always 
present the symptoms of a pneumonia in preparation for the evacua- 
tion by the lung. The physical signs will be the same, but the his- 
tory of the case will exhibit important differences : in the one case the 
accumulation of fluid will have been preceded by the signs and symp- 
toms of pleurisy or pleuro-pneumonia ; in the other, by the signs and 

* Dr. Samuel Fenwick, "Lancet," November lY, ISVT, "On the Detection of Particles 
of Hepatic Structure in Abscess of the Liver." The pus is shaken up with some distilled 
water and put aside in a conical wineglass. When settled, it is examined with the mi- 
croscope, or it is shaken up with some distilled water to which a few drops of ammonia 
have been added, and then, after subsidence, examined. 

f Dr. W. Crumb, "Philadelphia Medical and Surgical Reporter," March 14, 18T3. 



190 



DISEASES OF THE LIVER. 



symptoms of hepatic inflammation. Here, again, tlie aspirator may 
be invoked to make the diagnosis clear — the presence or absence of 
bits of hepatic tissue will prove the abscess to involve, or not, the liver- 
substance. 

Treatment. — As suppuration occurs so promptly after the initial 
hypersemia, it is doubtful whether any effort to prevent the formation 
of pus can be successful, but the extension of the area maybe checked 
or limited. As soon as the symptoms manifest themselves, a large 
dose of quinia (twenty grains) should be given at once, and decided 
cinchonism be maintained by the same dose at proper intervals, or by 
smaller doses more frequently. That quinia has the power to check 
the migration of the white corpuscles is well established, but it is 
equally true that large doses are necessary to accomplish this. Mor- 
phia should be combined with it, unless some contraindication exist, 
and especially if there be much pain and the peritoneum be involved. 
Warm fomentations and turpentine-stupes should be applied over the 
right hypochondrium. At the earliest moment when the existence of 
pus can be made out, or there are good reasons to suspect its presence, 
an exploratory puncture with the aspirator should be made. The re- 
cent experiences of Cameron,* Condon, f and Sachs]; have demon- 
strated that when the pus can be reached and evacuated a very large 
proportion of cases recover immediately. It is a remarkable fact that 
many cases in which the symptoms of abscess exist, and yet no pus is 
found, are greatly benefited by the puncture. The modern experiences 
have demonstrated also that, penetrated by suitable needles, no injury 
is done to the liver, and that repair takes place so perfectly that after 
death no trace of the operation is visible. The necessity for early 
evacuation of the pus consists in this, that only a portion of these ab- 
scesses are confined by a limiting membrane, and that those thus re- 
stricted do not long remain encapsulated, but tend to make their way 
externally. In Condon's collection of cases there were eight of abscess 
evacuated by the trocar, of which four recovered, and three of hepa- 
titis, without suppuration, in which the trocar was inserted deeply in 
the right lobe, all of which were much relieved by the puncture and 
promptly cured. In Sachs's collection of twenty-one cases there were 
eight recoveries after puncture — being in the proportion of thirty-eight 
per cent. Under the old system of using the knife or trocar, when the 
pus was already pointing, as represented in the statistics of Waring, 
there were sixty-six deaths in eighty-one cases, making the percentage 
of recoveries 18*5. When the abscess is large, and repeated punctures 

* "The London Lancet," 1863, June 6th and 13th— "On the Treatment of Acute 
Hepatitis in its Suppurative Stage." 

f Ibid., August, 1877, Dr. E. H. Condon— "On the Use of the Aspirator in Hepatic 
Abscess." 

" Ueber die Hepatitis der heissen Lander," etc., von Dr. Sachs in Cairo, op. cit. 



ACUTE YELLOW ATROPHY. 



191 



are necessary, the author has had excellent results from the injection 
of tincture of iodine ; it lessens the formation of matter and prevents 
its decomposition. Mercury was formerly much used in all hepatic 
affections, but that it is injurious in abscess is now disputed by no one. 
It is probable that the sulphides, so much and successfully employed in 
external suppuration, will be found adapted to the treatment of hepatic 
abscess. The sulphides of sodium and calcium and the sulphurous 
mineral waters are suitable agents to be so exhibited. As the vital 
resources of the patient are severely strained, the strength should be 
carefully husbanded from the beginning. The diet must be generous, 
and stimulants judiciously administered. When suppuration has oc- 
curred, the alcoholic stimulants must be given freely. For the dysen- 
tery present in so many cases, ipecac is the best remedy, if prescribed 
in the necessary quantity — ^] every three or four hours. If there 
are present old ulcerations of the intestinal tract, copper sulphate is an 
efficient remedy ; but usually the astringents in turn will be adminis- 
tered in vain. 

GENERAL PARENCHYMATOUS HEPATITIS— ACUTE YELLOW 

ATROPHY. 

Definition. — As the hepatitis terminating in suppuration is con- 
fined to a part of the liver, it has been designated Local Parenchyma- 
tous Hepatitis, while the term General Parenchymatous Hepatitis is 
applied to Acute Yellow Atrophy, which consists in an acute diffused 
inflammation involving the whole organ, and terminating in atrophy. 
Various names have been applied to this disease, as " malignant jaun- 
dice," " typhoid icterus," " hgemorrhagic icterus," etc. 

Causes. — Various theories have been proposed to account for the 
origin of acute yellow atrophy. It has been referred to an excess in 
the production of bile, to stasis of the bile, to sudden saturation of the 
hepatic cells with biliary matters contained in the blood of the portal 
vein. Budd supposes it to be caused by some special blood-poison of 
unknown nature, which acts especially on the liver. These hypotheses 
are without facts to support them. That it is an acute, diffuse, paren- 
chymatous inflammation is established by the most recent investiga- 
tions, but the exciting cause of this inflammation remains unknown. 
That it is in the nature of a specific morbid poison seems probable, 
since other organs are simultaneously attacked. It may be that the cir- 
cumstances are such as to cause the formation of a peculiar ptomaine. 
There are certain points in the etiology of the disease, however, which 
are well known ; it occurs most frequently in the female sex, and dur- 
ing the state of pregnancy. According to the statistics of Frerichs, 
in thirty-one cases of this disease twenty-two were females, and one 
half of these were attacked during the state of pregnancy. It occurs 
from the third to the sixth month of pregnancy, and in comparatively 



192 



DISEASES OF THE LIVEK. 



young subjects, under forty, and rarely indeed after thirty years of 
age. Otber causes have been supposed to exert an influence in its 
production : as anger — a violent passion having been the apparent 
cause in cases reported by the older writers — venereal excesses, syphi- 
litic infection, and local miasms. Acute atrophy of the liver has been 
induced by the changes resulting from typhus fever. A condition 
analogous to it is brought about by the action of phosphorus, arsenic, 
antimony, and certain other minerals, and a similar state has been in- 
duced by subacute alcoholismus (Rendu). 

Pathological Anatomy. — The liver presents a most characteristic 
appearance — it is much smaller, flattens out by its own weight, is soft 
so that it tears easily, and has a uniform yellow color. The peritoneal 
layer is roughened and wrinkled. On microscopical examination, the 
changes seen are those due to interstitial and parenchymatous exuda- 
tion. There is, at first, an hypersemia, traces of which are discoverable 
at various points, the rest of the organ being anaemic, a result of the 
subsequent atrophy and obliteration of vessels. Between the lobules 
there is deposited a grayish-yellow material, which widens the inter- 
lobular space, and in those cells which are still recognizable is con- 
tained a quantity of an albuminous and fatty matter mixed with pig- 
ment.* In the place of the disintegrated cells there is formed a quan- 
tity of brownish, fatty granular matter ; fat-globules ; pigment ; bac- 
terian colonies,! and needles of tyrosin and leucin. The ultimate 
radicles of the portal system and the hepatic artery are obstructed or 
obliterated. The kidneys also undergo characteristic changes, espe- 
cially in the cases occurring in pregnancy. The organs are thoroughly 
stained by the icteric urine, especially the endothelium of the tubules, 
and besides the cells of the endothelium have become infiltrated by a 
granular albuminous matter, and are undergoing fatty degeneration. 
The urine is heavily loaded with bile-pigment, and usually contains 
some albumen ; the urea is diminished or has disappeared, and is re- 
placed by leucin and tyrosin. In the normal condition of the liver it 
is now regarded as probable that the urea which is eliminated by the 
kidneys is produced in the former organs by the metamorphosis of the 
albuminoids. The blood contains considerable urea, and much leucin 
in acute atrophy of the liver. The spleen is usually, but not invari- 
ably, increased in size. The muscular tissue of the heart undergoes 
more or less fatty change, but this alteration is common to many acute 
diseases. Spots of ecchymosis form in the peritoneum, the gastro-in- 
testinal mucous membrane, in the skin, etc., and indicate the destruc- 
tive changes which have occurred in the blood. 

Symptoms. — This formidable malady begins insidiously — as a sim- 

* Drs. Lewitski und Brodowski— Virchow's Archiv," Band Ixx, p. 421— "Ein Fall 
von sogennanter acuter gelber Leberatrophie." 
f Ibid., Band xliii, p. 533. Waldeyer. 



ACUTE YELLOW ATROPHY. 



193 



pie catarrh of the stomach and duodenum, with a slightly coated 
tongue, nausea and vomiting, headache, tenderness of the epigastrium, 
and a slight icterode hue of the skin which gradually deepens. There 
are' some acceleration of the circulation and slight fever, which, how- 
ever, are not constant, for the pulse may and usually does have the 
feebleness and slowness belonging to jaundice. The duration of these 
mild symptoms is by no means constant — they may occupy a week or 
more ; and, from the appearance of decided jaundice to the onset of 
the serious symptoms, there may be a few hours to two weeks. Some- 
times the severe symptoms come on with the jaundice and a day or 
two before the temperature rises. An obstinate insomnia now begins, 
and the headache becomes intense. This period has, by some,* been 
entitled the icteric period. According to Frerichs, these symptoms of 
gastro-duodenal catarrh exist in about one half of the cases, and the 
duration of them may be from three to five days, although in some 
cases they last two to three weeks. In one casef an attack of jaun- 
dice preceded, by several months, the fully developed attack. 

A rise of temperature either precedes or accompanies the serious 
symptoms — the toxmnic period. The pulse becomes very rapid, rising 
to 140, but suddenly again, without any apparent reason, it may be, 
or in consequence of hsemorrhage, falling to 70 or 80. These fluctua- 
tions, which may occur several times a day, are peculiar to the dis- 
ease. When the cerebral symptoms come on, the pulse becomes uni- 
form at 140 to 160. The temperature line is of the remittent type, 
with a morning remission (102° Fahr.) and an evening exacerbation 
(104° Fahr.). Jaundice is constantly present, and gradually deepens 
from its first appearance ; and intermixed with it are large brownish 
ecchymotic patches, but these are not always present. The tongue 
and gums are brownish, dry, and covered with sordes and crusts, and 
the breadth is fetid. There are much nausea and vomiting, and 
severe pain is experienced in the epigastrium and through the right 
hypochondrium, and pressure over the hepatic region awakens severe 
pain. A diminution in the size of the liver can be readily made out 
by percussion, and at the same time and relatively an increase in the 
dimensions of the spleen. There is constipation in the beginning, 
followed by more free, tarry stools, the product of intestinal hoemor- 
rhage. During the first vomiting, mucus and bilioas matters are dis- 
charged ; but, when the toxsemic symptoms come on, blackish, gru- 
mous blood, or " coffee-grounds," are ejected. There are more or less 
epistaxis, bleeding of the gums, as well as vomiting of blood, and 
ecchymoses form at various places. The urine is usually normal in 
quantity, acid in reaction, and has the normal specific gravity. When 

* Jaccoud, vol. ii, p. 418. 

f Dr. Joseph Coates, *'The British Medical Journal," June 26, ISTS. 
15 



194 



DISEASES OF THE LIVER. 



delirium and coma exist, the urine is either retained or passed invol- 
untarily. Very great changes are noted in its composition : the urea 
is diminished in amount, the phosphate of lime disappears, and a quan- 
tity of leucin and tyrosin and extractives are substituted. It contains 
also bile-pigment and traces of albumen, and cast-off epithelium deeply 
stained with bile-pigment. There must necessarily accumulate in the 
blood those excrementitious matters which it is the office of the liver 
to separate from the blood, and this fluid is deprived of those con- 
tributions to it made by the action of the bile in the digestion of cer- 
tain aliments. We can not therefore subscribe to the doctrine of 
Flint, who assigns to cholesterin the toxic effects, which are doubtless 
produced by several excrementitious matters. Instead of the "cho- 
lestersemia " of Flint, we hold to the older term, cholaemia or acholia. 
These poisonous materials act on the nervous system in a manner 
similar to a narcotic poison, producing at first a stage of excitation, 
followed by depression. A hypochondriacal state, with irritability and 
restlessness, is the first manifestation of mental disturbance, but this 
is soon followed by noisy delirium. From this state to low-mutter- 
ing delirium and coma the transition is quick ; or convulsions, local 
twitching, cramps, and general epileptiform attacks occur, soon pass- 
ing into coma and insensibility. Sometimes death takes place in te- 
tanic spasms.* 

Course, Duration, and Termination. — The behavior of acute atrophy 
of the liver is irregular : the prodromic period, the stage of jaundice, 
and the toxsemic stage, are uncertain in duration, but the last stage 
follows a more uniform plan. After the development of the jaundice 
period, from the rise of temperature and the insomnia which mark the 
onset of the toxsemic stage till death, the most usual period is five 
days. The prodromic stage may last a week or two, the jaundice 
stage from a day or two to two weeks, the toxoemic stage a week, but 
the rule is that the whole course of the malady is included within a 
week. The termination is in death. Some successful cases have been 
reported, but it is doubtful if they were genuine. It may be that 
many cases treated carefully at the outset have been arrested and 
cured, but such cases are, as far as we are informed, simply cases of 
jaundice from catarrh of the bile-ducts. When the hepatic cells are 
disintegrated, a cure can hardly be possible. 

Diagnosis. — Acute atrophy is probably more frequently overlooked 
than recognized. It is impossible to differentiate the gastro-duodenal 
catarrh of this disease from the ordinary examples of the same dis- 
ease. Great importance must be attached to the increased headache, 
rise of temperature, and obstinate wakefulness which mark the onset 
of the toxsemic stage. As so many of these cases occur in pregnant 

* Morand, " Gazette dcs Hopitaux," 20, 21, 1873. 



AMYLOID LIVER. 



195 



women, thej are apt to be confounded with puerperal fever, puerperal 
septicaemia, etc. ; but the physical signs of a rapidly diminishing liver, 
the nervous phenomena, the haemorrhages, and especially the changes 
in the urine, will serve to distinguish between them. 

Treatment. — Frerichs reports a supposed case of acute atrophy, 
which got well under purgatives and mineral acids. This appears 
to be the routine treatment. If the disease had any relation to the 
amount or quality of the bile, the use of podophyllin, euonymin, ipe- 
cac, and other remedies of the same group, is indicated, and mineral 
acids should be given freely, well diluted, in small doses frequently 
repeated. As the disease is a diffuse parenchymatous inflammation, the 
best results will be obtained from the use of a large dose of quinia and 
morphia in the incipiency, but will be useless when the liver-cells have 
begun to disintegrate. The author advises the trial of very small 
doses of phosphorus, as early as possible, as this remedy affects the 
organ specifically, and an action of antagonism may be discovered 
between them. This remedy, as all others, will fail to do the least 
good, if disintegration of the cells has occurred. Alcoholic stimulants 
should be pushed freely, notwithstanding a condition not unlike acute 
atrophy has been lately observed from subacute alcoholismus.* 

AMYLOID LIVER. 

Definition. — By this term is meant a degeneration of the liver caused 
by the deposit of an albuminoid material, termed amyloid^ because of 
a superficial resemblance to starch-granules. This disease is also called 
" waxy liver," and " lardaceous liver," in recognition of the peculiar 
physical condition of the organ. 

Causes. — The chief cause of amyloid degeneration of any organ is 
prolonged suppuration, especially in connection with diseased bone, 
and the morbid process is then general, the liver suffering in common 
with other organs. A variety of explanations have been offered to ac- 
count for the production and deposit of this amyloid matter. The 
theory of Dr. Dickinson, which assumes that this matter is a form of 
fibrin, altered by the loss of its alkali, which in the normal state is 
intimately associated with it, has been overthrown, by the recent in- 
vestigations of Mr. George Budd, Jr.f In the blood, as Seegen first 
demonstrated, there exists a substance — dystropodextrm — " which 
agrees with lardacein in its most essential characteristic." This ma- 
terial, it is now supposed, becomes insoluble and is precipitated in the 
textures, under those conditions with which we are now familiar as 
causative of the morbid state. The suppuration of tubercular cavi- 

* M. H. Rendu, " Note sur deux eas d'alcoolisme subaigu ayant donne lieu des acci- 
dents comparables h. ceux de I'ictere grave." " La France Medicale," September 17, 18'79. 
f London *' Lancet," February and March, 1880. 



196 



DISEASES OF THE LIVER. 



ties, of scrofulous abscesses, of intestinal and leg ulcers, etc., may also, 
although less frequently, be a cause of this degeneration. Next to 
suppuration, the most influential factor is chronic syphilitic infection, 
and then chronic malarial poisoning. The abuse of mercury is an 
alleged cause which Frerichs disposes of satisfactorily. This morbid 
state occurs more frequently in men than in women, and attacks by 
preference the most active period of life — from twenty to forty years 
of age. 

Pathological Anatomy. — The liver presents a very characteristic 
appearance : it is uniformly enlarged without alteration of the form 
and relation of its parts, and sometimes its dimensions are enormous. 
It presents to the naked eye a pale grayish, glistening, opaline, trans- 
lucent appearance, and to the touch a doughy consistence. On section 
the surface is homogeneous, and resists the knife almost like cartilage, 
and is anaemic and whitish ; and when the disease is far advanced no 
trace remains of the proper structure of the organ.* There may be 
parts only, or the whole organ, affected by the change. The deposits 
may be in patches, small or large, and restricted to parts of the organ, 
or be uniformly distributed through it, and may be so limited in amount 
as not to increase its size (Frerichs). f Cirrhotic or fatty degeneration 
may coexist with the lardaceous, when, of course, the appearances will 
correspond. The reaction with iodine and sulphuric acid affords a 
striking test of the amyloid deposits. The parts to be examined must 
be carefully cleansed, and a solution of iodine with iodide of potassium 
in water, or diluted tincture of iodine, brushed over, when they assume 
a mahogany color, quite different from the yellow color of the healthy 
tissue. This reaction may be sufficiently characteristic of itself, but, if 
to the iodized surface is now added some diluted sulphuric acid, the 
affected parts, after some minutes or hours, take on a violet tint, more 
rarely bluish. The violet may be very deep, almost black. Orth ^ 
advises that a large and thin section be laid in a saucer of water con- 
taining some iodine, and, when the changes are complete, placed on a 
white plate. The reaction will be very distinct. Microscopically, the 
structural alterations affect first the arterioles and capillaries ; their 
diameter is increased, the lumen narrowed, even closed ; the intima, 
the endothelium, and the muscular coat, more rarely the adventitia, are 
invaded by the deposits. The cells become cloudy, granular, then 
clear, bright, and homogeneous, and the nuclei disappear. When the 
process is completed, the cell is transparent, glistening, and brittle, 
easily breaking up into small fragments.§ The amyloid change is not 

* Wagner, " Manual of General Pathology," p. 322. New York : William Wood & 
Company. 1876. 
f Op. cit. 

\ Orth, "Diagnosis in Pathological Anatomy," p. 321. Riverside Press. 1878. 
§ Forster, op. cit.., p. 272. 



AMYLOID LIVER. 



197 



confined to the liver, but involves the spleen, the kidneys, the lymphatic 
glands, the intestinal raucous membrane, and other organs. Those por- 
tions of the liver remaining unaffected by this morbid deposit are in a 
state of congestion, and are softer ; or parts of the organ are attacked 
with fatty or cirrhotic degeneration, or syphilitic gummata may be 
mixed up with the amyloid deposits. 

Symptoms. — There are probably no exceptions to the statement that 
amyloid degeneration occurs in subjects already in a cachetic state by 
the existence of one or more of the causes already mentioned. The 
symptomatology is necessarily that of the malady with which this 
degeneration is associated, up to the time of the development of those 
signs by which the disease of the liver is recognized. The liver is 
usually enlarged, and often considerably so, extending several finger- 
breadths below the margin of the false ribs. The organ is smooth, 
firm to the touch, almost of stony hardness, it may be ; its borders 
well defined, free from pain or tenderness, unless there is present local 
peritonitis. This increase of size has gone on without any local uneasi- 
ness to call attention to the organ. The spleen is also enlarged, and 
is firm in texture, as a rule, but the waxy degeneration does not always 
affect it when enlarged in the course of amyloid liver. Jaundice is 
exceptional, unless the common duct or the hepatic duct is obstructed 
by enlarged lymphatics. As the amyloid change first affects the 
branches of the hepatic artery, the portal is not interfered with until 
later. Ascites exists in about one fourth of the cases, and is often pre- 
ceded by oedema of the lower extremities, the result of a general hydrae- 
mia. The appetite is usually poor, but in exceptional cases is voracious. 
Food in the solid form excites uneasiness soon after it is swallowed, 
and is rejected by vomiting, or passes unchanged in the faeces, unless 
it is very bland and capable of entire solution in the stomach. The 
fatty, starchy, and saccharine articles of the diet undergo decomposi- 
tion in the intestine, and a great deal of gas — the foul compounds of 
hydrogen with sulphur and phosphorus — is the result. The amount 
of bile passing to the intestine lessens with the increase of the deposit 
in the hepatic cells, and ultimately the secretion is arrested, and the 
office of the bile in preventing putrefaction and in emulsionizing the 
fats terminates. The obstruction to the portal circulation maintains a 
constant hyperaemia of the gastro-intestinal mucous membrane. As a 
result of these causes, the stomach and intestines become irritable, and 
frequent liquid stools, now pale from the absence of bile, now dark 
from the presence of blood, are passed. Amyloid degeneration also 
invades the arterioles of the mucous membrane and the substance of 
the villi, and destructive ulcers are formed in consequence (Frerichs). 
The urine is pale, abundant, of low specific gravity, and contains 
waxy casts and a trace of albumen. It is not surprising, in view of 
the structural alterations and impairment of functions, that the sub- 



198 



DISEASES OF THE LIVER. 



jects of amyloid degeneration present a peculiar, anjemic, and pallid 
appearance, are breathless on the least exertion, and emaciate rapidly. 

Course, Duration, and Termination. — As amyloid degeneration is 
preceded by suppuration, or some chronic wasting disease, the moment 
this change begins escapes recognition. Indeed, the peculiar deposits 
have been quite extensively distributed before any characteristic symp- 
toms appear. When the process once begins it extends at a pretty 
uniform rate, and death takes place by exhaustion and general dropsy, 
or the end is reached by an intercurrent malady, as pneumonia, pleurisy, 
etc. Its course is essentially chronic ; its duration months or a year 
or more ; its termination fatal. Notwithstanding the unfavorable 
prognosis, the disease is not always fatal, and cures have been report- 
ed, especially of those cases having a syphilitic history. 

Diagnosis. — The enlargement of the liver due to amyloid deposit 
is to be differentiated from fatty liver, hydatid disease, cancer, etc. 
From fatty liver it is distinguished by the greater firmness of texture, 
the Avell-defined margin, and especially by the accompanying disorders 
of the spleen, kidneys, and intestinal canal. From hydatid disease it 
is separated by the same signs, and by the characteristics of the hyda- 
tid tumor, which enlarges painlessly, is elastic, and furnishes on pal- 
pation the " purring tremor." The changes in the liver produced by 
cancer are secondary to the original deposit, which is most frequently 
in the stomach, and the enlargement of the organ is hard, nodular 
and irregular. The urinary secretion is not affected in cancer, but 
jaundice is often present. 

Prognosis. — Few if any cases of true amyloid disease recover, and 
indeed recovery can hardly be possible when the hepatic cells are en- 
tirely filled with such a material. Cases presenting the signs of amy- 
loid degeneration, but not far advanced, have recovered. Although 
the prognosis is grave, it is not necessarily fatal. 

Treatment. — Prophylaxis necessarily occupies an important position 
in the therapeutical management of this disease. As so many — much 
the largest number — owe their origin to suppuration of bone and to 
syphilitic infection, it is highly necessary to stop the influence of these 
morbid processes at an early period in all cases. If there be any rea- 
son to suspect constitutional syphilis, appropriate treatment should be 
at once instituted, and the most efficient remedy under these circum- 
stances is a compound of iodine : the compound solution of iodine — 
ten drops in water, three or four times a day, may be given ; or, if 
there be much anaemia, the sirup of the iodide of iron, and especially 
the sirup of the iodides of iron and manganese. The author has had 
the best results from the persistent use of the iodide of ammonium in 
small doses frequently repeated — five grains every four hours, and 
well diluted with water. Budd urges the employment of the muriate 
of ammonia (ammonium chloride), but the iodide, the author believes. 



CARCIXOMA OF THE LIVER. 



199 



is mncli more efficient. Mercurials are injurious. The diet should 
consist of those alimentary principles which undergo digestion and ab- 
sorption in the stomach — as milk, animal broths, eggs, fish, etc. ; and 
starches— as bread, potato and rice— sugar in any form, and fats, ought 
to be avoided, because they require the action of the intestinal juices. 
The food-supplies should be small in quantity, and given frequently, 
because of the intolerance of the gastro-intestinal mucous membrane. 
Inunction of fat, especially of cod-liver oil, is a highly useful addition 
to means for promoting the nutrition. 



CARCINOMA OF THE LIVER. 

Etiology —Xothing is definitely known as to the origin of cancer, 
in any situation, but there are certain facts connected with its develop- 
ment which it is important to recognize. It is a disease of advanced 
life, and is more apt to appear from forty to sixty than at any other 
vigintennary. But cancer of the liver appears in early life relatively 
more frequently than cancer of the stomach. It occurs with about 
equal frequency in the two sexes. Heredity, although the fact can 
not be expressed in figures, is doubtless the most influential factor in 
its genesis. 

Pathological Anatomy. — The ordinary form of cancer is found in 
the liver, the variety being determined by the relative proportion of 
the fibrous stroma, the cells, and the juice ; it is most frequently 
medullary or encephaloid. When infiltrated with pigment it becomes 
melanoid, and, when vessels predominate, telangiectatic cancer, but 
these are accidental differences. The cancer formation may be in 
nodules or isolated masses, or diffused through the hepatic parenchyma. 
The size of the nodules varies from the dimensions of a pea to those of 
a child's head (Forster), and they are in numbers inversely as their 
size. There may be one or two of large size, or a great many of small 
size, distributed through the substance of the organ. Those on the 
surface are rounded, with a central umbilication, produced by a fatty 
metamorphosis of the center of the mass and contraction of the pe- 
ripheral portion. The peritoneum is adherent usually, and is cloudy, 
thickened, and covered with a membranous exudation, or it may re- 
main normal. The consistence of the masses varies with the form of 
the cancer — it is soft, brain-like, or almost creamy, or it is hard and 
cartilaginous. The explanation of the origin of the growth differs, but 
it may be stated that the cancer develops from the interlobular con- 
nective tissue. The branches of the hepatic artery are intimately con- 
cerned in the morbid process ; they increase in size, and permeate the 
new formation, while the branches of the portal vein shrink. "With 
the development of the cancer-cells (by division and endogenous for- 



200 



DISEASES OF THE LIVER, 



mation of the connective-tissue corpuscles — Wagner *) the proper he- 
patic cells disappear. The new vessels developed from the branches 
of the hepatic artery have very delicate walls, and are liable to rup- 
ture, infiltrating the cancer-masses with hsemorrhagic extravasation. 
When the periphery of the organ is reached by the new formation, 
hgemorrhage may take place into the peritoneum, and sudden death 
ensue from this cause. The branches of the portal vein are compressed, 
or they may be filled with cancer-cells. The lymph vessels and glands 
may also become filled and infiltrated. The bile-ducts are compressed 
and disappear, except the larger ducts, which become dilated into 
pouches with retained bile, or pass unchanged through the cancer- 
masses. The growth of cancer is not continuous and uniform, but 
paroxysmal, as it were — now rapid, now slower ; and when the forma- 
tions have existed for some time they undergo a fatty metamorphosis. 
It is this change in the interior of the nodules which leads ultimately 
to the umbilications already mentioned. The hepatic parenchyma not 
invaded by the cancerous new formation remains unchanged, or is 
more or less hypersemic, or undergoes atrophy. The size of the whole 
organ is usually increased, and sometimes if attains extraordinary 
dimensions, weighing ten, fifteen, or twenty pounds (Frerichs). Can- 
cer of the liver is rarely primary, but is secondary to a deposit 
elsewhere, most frequently in the stomach. Of ninety-one cases col- 
lected by Frerichs, forty-six were secondary to cancer in organs hav- 
ing a vascular communication with the liver, and cancer was primary 
to the liver in scarcely one fourth of the cases. The author has met 
with one case of primary cancer of the gall-bladder, the morbid pro- 
cess apparently beginning in the exudation of a local peritonitis caused 
by the passage of hepatic calculi. 

Symptoms. — Cases of cancer of the liver are occasionally encoun- 
tered in which no characteristic symptoms existed ; the patient has 
ill-defined uneasiness in the right hypochondrium, disorders of diges- 
tion, and low spirits ; he emaciates progressively, is cachectic, and 
ultimately dies. Again, cancer of the liver has a clinical history which 
is merely the conclusion of a series of symptoms referable to cancer in 
another organ, notably the stomach. The defined symptoms of hepatic 
cancer are apt to be obscured by some leading condition associated 
"with it, as ascites. Those attacked with cancer are advanced in life 
as a rule. Before any symptoms of disturbance in the hepatic func- 
tions manifest themselves, there are present disorders of digestion, 
flatulence, and constipation. Then feelings of uneasiness, of weight, 
of tension, and of pain in the right hypochondrium are experienced. 
On palpation, soreness is developed by pressure, and the liver is felt 

* " General Pathology." Translated by Drs. Van Duyn and Seguin. New York, 1576, 
p. 503. 



CARCINOMA OF THE LIVER. 



201 



Btretcbing beyond the margin of the ribs ; it is indurated, irregular in 
outline, and nodulated. In the further progress of the case, the liver 
extends downward still more, and nodules can be easily made out ; the 
area of hepatic dullness is increased in all directions, but chiefly down- 
ward, and there may be a good deal of spontaneous pain and exquisite 
tenderness on pressure by reason of a local peritonitis. 

Jaundice is not present in the ma- 
jority of cases, and exists only when 
the lymphatic glands in the fissure or 
the cancer nodules are enlarged suffi- / 
ciently to compress the hepatic or / 
common duct. Ascites is present in ; 
about one half of the cases, and is pro- i: 
duced more frequently by peritonitis r 
than by compression of the portal, but 
this vessel is obstructed occasionally 
by cancer thromboses. The ascites 
may be so considerable as to produce 
great distress by embarrassment to 
respiration and by interference with 
the circulation. The ascites may be 
in part due to the watery condition of 

the blood. The fluid is a pale, straw- Fig. U.-Area of Dullness in Cancer of the 

colored serum, or it contains flocculi 

of lymph and is turbid, or it is mixed with blood, the source of which 
has been heretofore alluded to. Gastro-intestinal catarrh is set up by 
the congestion of the portal system ; haemorrhoids form ; haemorrhages 
occur from the intestinal mucous membrane, and an obstinate watery 
diarrhoea succeeds to the constipation which was an early symptom. 
All of these causes combine to produce a cachectic state. The com- 
plexion gradually assumes the characteristic earthy or fawn color, 
emaciation is extreme, the feebleness is excessive, the hands and feet 
are cold, the skin is dry and harsh, and the expression is dejected and 
worn. 

Course, Duration, and Termination. — The course of cancer of the 
liver and its duration are much influenced by its form — the medullary 
proceeding to a fatal termination more rapidly than scirrhus. As 
already stated, the progress is not uniform, the growth at times being 
suspended and then again quickening into renewed activity. Cases 
terminating in eight weeks have been reported, and others continue 
with varying fortunes for months and years. There is but one mode 
of termination, that in death. 

Diagnosis. — It may not be possible to diagnosticate cancer in 
those cases without any local symptoms, or in the incipiency of 
any case. When, however, the enlarged and nodulated liver can bo 




202 



DISEASES OF THE LIVER. 



felt, the diflSculty of diagnosis is much less, especially if the patient 
is of advanced age, and the cachexia, the ascites, etc., are also pres- 
ent. Distinction is to be made between cancer, abscess, echinococ- 
cus, and amyloid disease ; in all these the liver is enlarged (as a rule) 
and projects downward, but, in cancer, the organ is nodulated and 
indurated ; in abscess it is smooth and softer, and may be fluctu- 
ating ; in echinococcus it is smooth, elastic, and having the purring 
tremor ; in amyloid it is smooth and uniform, but indurated. They 
differ in their clinical history and in their cause, in their duration and 
in their termination, so that a diagnosis can, in well-marked cases, 
be readily made. 

Treatment. — The treatment must necessarily be palliative and symp- 
tomatic, as there is no remedy for cancer in any situation. Anodynes 
will be required to relieve pain. Careful regulation of the diet, ac- 
cording to the conditions present, and the timely administration of 
stimulants will be demanded. Ascites will require the treatment in- 
dicated for that disease, especially the tapping — for the interference 
with repose caused by a distended abdomen is one of the most distress- 
ing complications. 

i30HINOCOOCUS OP THE LIVER (HYDATID DISEASE OF THE 

LIVER). 

Definition. — By the terms echinococcus of the liver, hydatid dis- 
ease, cystic degeneration, multilocular cyst, etc., is meant the penetra- 
tion into the liver of the scolex of the sexually immature taenia echi- 
nococcus. The embryos, gaining access to the intestines of man, mi- 
grate, and, doubtless chiefly by the portal vein and bile-ducts, reach 
the liver in which the cyst or cysts develop, sometimes attaining im- 
mense size. 

Causes. — As the echinococcus is the taenia of the dog, only those who 
live in a humble way, with their animals about them, suffer from these 
migratory parasites. As the ova are discharged with the excrement 
of the dog, it is obvious that they can gain admission to the human 
stomach only through the most filthy practices, or by carelessness in 
the obtaining and storing of drinking-water and food. In Iceland, more 
than in any other part of the world, do the people suffer from cystic 
disease — as large a proportion as one sixth of the population being 
infected. This preponderance of the disease is due to the number of 
dogs and to the promiscuous way in which the members of a family 
and their dogs live together in their wretched hovels. The disease 
occurs at the middle period of life chiefly, and rarely in the young. 
In the only case of echinococcus of the liver met with by the author, 
the patient, a male, was forty-two years of age. 

Pathological Anatomy, — When the echinococcus (or two or more) 



HYDATID DISEASE OF THE LIVER. 



203 



lodges in the liver it is presently enyeloped in a tough, fibrous, yellow- 
ish-white membrane, constructed out of the adjacent connective tissue, 
and closely adherent. Within this adventitious membrane is contained 
the embryo, inclosed in a clear, translucent sac made up of numerous 
concentric layers. This sac of the embryo is the mother-sac, and in the 
interior of it a number of so-called daughter-vesicles, and still other, 
granddaughter- vesicles, are developed, and ultimately the mother-sac, 
with its investing membrane, attains to extraordinary dimensions. The 
daughter-vesicles vary in number from a few up to many thousands, 
and in size from that of a pea to that of a goose-egg. The fluid of the 
sac is clear, opalescent, weakly alkaline, and of a specific gravity of 
I'OOS to 1*013 ; it contains no traces of albumen, but a large proportion 
of sodium chloride and some crystals of cholesterine and hsematoidine.* 
The inner membrane of the daughter-vesicles is lined with a germinat- 
ing layer, from which the embryos spring ; and scolices, attached as 
well as free, can be observed within the sacs. These scolices are the 
immature tsenise, and can be recognized with a low power — sixty diam- 
eters — as possessed of a head, four suckers, and a row of booklets. 
When detached, these scolices have the power of active motion, and 
can withdraw their probosces and booklets within their own cavity. 
There are hydatids without daughter-vesicles, and others entirely with- 
out a scolex, which were denominated by Laennec acephalocysts, and 
by Kuchenmeister,f sterile echinococci. There are great variations 
in the size, number, and position of the cysts. They are found in 
all the lobes, but most frequently in the right, buried in the sub- 
stance or projecting from the surface of the organ. Usually but one 
cyst exists, but there may be several — as many as five or six. It 
follows that the size, shape, and appearance of the liver will vary 
with the number, position, and growth of the cysts. It may attain 
a sufficient size to distend the abdominal cavity, or at least make a 
great protrusion in the right side. With the growth of the cyst, 
the hepatic tissue is correspondingly atrophied, by being encroached 
upon, while the rest of the organ remains intact, or undergoes hyper- 
trophy, or is hypersemic. As a rule, the cysts do not obstruct the 
large blood-vessels and bile-ducts ; hence the infrequency of ascites 
and jaundice ; yet both may be encroached upon — even obliterated. 
It sometimes happens that communication is established between bile- 
ducts and the cyst, by the breaking through of the duct in the course 
of development of the cyst, and, bile entering, the growth of the echi- 
nococcus is arrested. The cysts sometimes penetrate the common duct, 
also the gall-bladder, and rarely the portal vein. They may be dis- 
charged through the ducts and a cure be thus effected, but, if they 

* Davaine, "Traite des Entozoaires." Paris, 18'72, p. 379. 
f " Animal and Vegetable Parasites," op. cit. 



204: 



DISEASES OF THE LIVER. 



enter the veins, thrombi form, with the usual disastrous results. Echi- 
nococci-cysts may undergo calcification. The adventitious envelope 
becomes thicker and tougher, and calcareous salts are deposited ; ex- 
pansion and growth are prevented ; the parasites die, and are found 
flattened and contracted. In other cases there is developed in the 
interior of the capsules a dense, honey-like or puriform fluid, which 
had previously been clear and then milky, and remains of the scolices, 
especially the booklets, are found floating in, or mixed with, the con- 
tained fluid. Crystals of hiematoidine and bile also are found mixed 
with the contents of wasting cysts. 




Fig, 16.— Taenia ec/dnococcus, from the Fig.- Fro. IL—Tepniaecldno- 

coccuti, from the Dog. 



A great many cysts are destroyed and cease to grow, as has been 
described, but many continue to enlarge, pushing up the diaphragm 
and displacing the heart, and reaching sometimes as high as the second 
rib (Frerichs). Others, growing downward from the under surface of 
the liver, push aside the stomach, and force the abdominal organs into 
the pelvis, or, but rarely, compress the ascending vena cava, causing 
oedema, varicose veins, etc. A cyst may rupture into the cavity of 
the chest — into the pleural or pericardial sac, causing fatal inflamma- 
tion, or excavate a cavity in the right lung, and shreds and parts of the 
vesicles be discharged through the bronchi by expectoration. A cyst 



HYDATID DISEASE OF THE LIVER. 205 

may also rupture into the peritoneum, producing fatal peritonitis, or 
into the intestines, and be slowly discharged by stool. Rupture within 
the abdomen is usually due to a blow or other injury, but is sometimes 
spontaneous. The echinococcus multilocidaris^ which was formerly 
mistaken for colloid cancer, but has since been accurately described 
by Virchow, differs from the ordinary form, in that it is a very firm, 
hard tumor, consisting of dense fibrous tissue, containing cavities filled 
with a gelatinous material. On account of its tendency to ulcerative 
deo^eneration, Yirchow called it the " ulcerative multilocular echinococ- 
cus-tumor." Friedreich * holds that the development of this form 
takes place in the gall-ducts and blood-vessels. 

Symptoms. — A cystic tumor of small size, deeply placed, and not so 
situated as to interfere with other parts, may not cause any symptoms, 
and therefore remain undetected. But a cyst of considerable size, pro- 
jecting from the liver, or which has increased the size of the organ, 
and especially if it has encroached upon neighboring parts, will cause 
sufficient disturbance of function to lead to its early recognition. If 
a cystic tumor increases to any considerable extent the volume of the 
liver, there will be a feeling of weight, heaviness, and dragging in 
the right hypochondrium, and some disorders of digestion ; if it hap- 
pen to be near the hilus of the organ, the portal vein and the com- 
mon or the hepatic duct may be pressed 
upon, causing ascites and jaundice ; if 
near or at the upper convex surface of 
the right lobe, the diaphragm will be 
pushed up, and a dry cough and dysp- 
noea will be the result. The deo^ree 
of enlargement is necessarily various. 
The tumor may fill in the whole space 
from the inferior border of the second 
rib to the pelvis, displacing the tho- 
acic and abdominal organs, and forc- 
ing out the intercostal spaces. The 
tumor may take various forms : the 
liver may be uniformly enlarged ; 
there may be a growth projecting 
from the borders of the organ, and 
having a globular or hemispherical 
form similar to that of the gall-blad- 
der ; or, one lobe may be the seat of 
the growth, the other remaining intact 

On palpation, an hydatid tumor is elastic, resisting but soft, fluctu- 
ating, and, in somewhat more than half the cases, presenting the pecu- 

* Yircbow's Archiv," vol. xxxiii, p. 16, " Ueber multilokularen Leber-echinokokkus." 




Fig. is.— Liver enlarged by Hydatid Cysts. 



206 



DISEASES OF THE LIVER. 



liar fluctuation known as "purring tremor," or "hydatid purring" — 
a sensation appreciated by the sense of touch as the trembling of a 
bowl of jelly appears to the eye. The tumors are not painful, and it 
is exceptional for any tenderness to be felt on pressure. Jaundice or 
ascites occurs only in the rather rare event of a tumor near the hilus, 
or so situated as to compress the vein and duct. Dyspnoea and cough 
occur when the cyst develops into the thorax ; irregular action of the 
heart, when this organ is pushed from its position ; constipation and 
vomiting, when the intestines and stomach are encroached upon ; swol- 
len and oedematous feet and ankles and enlarged veins, when the cava is 
compressed. All of these symptoms arise, when the form and direction 
of the cyst develop them, without any constitutional disturbance, and 
if such disturbance occur it is due merely to the interference of the 
growth with important functions. If the echinococcus burst, new 
symptoms arise. If the stomach is entered, there will be some local 
pain, and the parasites will be rejected by vomiting, often in immense 
numbers ; if the intestine is perforated, the parasites are discharged 
by stool, and recovery may ensue in either case. If the vena cava is 
entered, sudden death with the symptoms of asphyxia takes place. If 
the pleural cavity receive the echinococci, pleuritis is excited, and the 
cysts, with the products of inflammation, may be subsequently dis- 
charged through the lung by a bronchus. If the pericardium is sud- 
denly filled with echinococci, the action of the heart is disturbed, and 
fatal pericarditis quickly excited. 

Course, Duration, and Termination.— The hydatid disease is essen- 
tially chronic in its course. The development of the cyst is affected 
by its surroundings ; and in the interior of organs, subjected to pres- 
sure on all sides, the growth is slower than if it is deposited on the 
surface. They last from one or two years up to thirty, but the most 
usual duration is two to four years. They may undergo a spontaneous 
cure : the echinococci die, or on the opening of bile-ducts they are 
killed by the entrance of bile, and subsequently shrivel up ; they are 
discharged through the stomach and intestine, or by the bronchi, and 
recovery slowly ensues. Death is not unfrequently produced by echi- 
nococci — by gradual failure of the powers of life ; suddenly, by en- 
trance of the parasites into the vena cava or the pericardium ; and 
gradual failure by pneumonia, or suppuration, or pyaemia. 

Diagnosis. — Echinococci of the liver may be confounded with ab- 
scess, cancer, dropsy of the gall-bladder, aneurism, and hydro thorax. 
It differs from abscess, cancer, and hydrothorax by the absence of pain 
and constitutional disturbance ; from abscess, by the character of the 
fluctuation ; and from cancer, by absence of the hard, non-fluctuating 
nodules of the latter. From dropsy of the gall-bladder it is distin- 
guished by the lack of a history of attacks of hepatic colic, their ces- 
sation and the enlargement of the gall-bladder coming on slowly ; but 



HYDATID DISEASE OF THE LIVER. 



207 



the distinction is most certainly made by the use of the aspirator, since 
it has been shown that this organ may easily and with perfect safety 
be penetrated by the needle. From aneurism, echinococci are readily 
differentiated by the existence of a heaving, expansile pulsation in the 
former, without the peculiar fluctuation of the latter. There is more 
real difficulty in separating hydatids pushing up the diaphragm, from 
effusions into the pleural cavity, as the physical signs are the same. 
An attentive consideration of the previous history will aid materially 
in arriving at conclusions. The growth of echinococcus is slow and 
painless, and the development of the local symptoms is free from that 
disturbance which precedes the occurrence of an effusion in the chest. 
But, above all other means for coming to a correct conclusion, must 
be placed the use of the aspirator and the microscopic examination of 
the fluid. 

Prognosis. — When the echinococcus is large, and its particular 
direction unknown, the prognosis is grave. The early use of the as- 
pirator enters largely into the question of prognosis, for early punc- 
ture will insure the death of the parasite. When discharge takes 
place by the stomach and intestine, the prognosis will be favorable ; 
and recovery may also be expected in those cases discharging by the 
bronchi, provided the right lung is only so far damaged as to permit 
the passage of the cysts. When there is a large suppurating cavity 
in the right lung the prognosis is unfavorable. 

Treatment. — There is no medicinal treatment which can in any way 
affect the origin or growth of the echinococci. Fortunately, we possess 
simple surgical measures by which these cysts may be safely and cer- 
tainly closed. These are, puncture by an aspirator needle and with- 
drawal of some of the fluid, and electrolysis. Whenever a cyst can 
be reached by the needle, it can be subjected to either of these expe- 
dients. The simple puncture and withdrawal of some of the fluid con- 
tained in the mother-vesicle should be tried first, as this has succeeded 
in numerous instances. This failing, the method by electrolysis should 
be practiced. Dr. Hilton Fagge and Mr. Durham * report eight cases 
in which electrolytic decomposition was employed with entire success. 
Two needles connected with the negative pole were inserted into the 
sac, and the positive pole, in the form of a large sponge-electrode, was 
applied on the integument in the neighborhood. Ten cells were used 
to furnish the current, and the needles were permitted to remain ten 
minutes. As, in the process of electrolytic decomposition, hydrogen and 
the alkalies (potassa, soda) appear at the negative pole, it is obvious that 
the parasites must be killed by the electrolytic action. Besides these 
measures, iodine has been injected into the mother-sac with success. 

* " Medico-Chirurgical Transactions," vol. cliv, " On the Electrolytic Treatment of 
Hydatid Tumors of the Liver, with an Addendum on Simple Acupuncture." 



208 



DISEASES OF THE LIVER. 



ANEURISM OP THE HEPATIC ARTERY.— The author can add 
one to the few examples of aneurism of the hepatic artery. The size 
of the tumor in the reported cases has varied, but the tumor can not 
always be felt, or rupture takes place before it has attained sufficient 
dimensions to be felt through the abdominal parietes. In one instance 
the liver was displaced by it. Usually, long before the existence of a 
tumor can be made out, severe pains are experienced in the right 
hypochondrium. The attacks of pain are at first paroxysmal, and can 
hardly be distinguished from hepatic colic, but in the further progress 
of the case there are constant pain and soreness in the right hypochon- 
drium, and paroxysms of severe pain. The pressure of the aneurism 
on the hepatic plexus is the cause of the early appearance, severity, 
and persistence of the pain. Jaundice is usually present, due to' pres- 
sure on the hepatic or common duct, and, in the case referred to by 
the author, ascites was the prominent symptom. The interference 
with the hepatic functions, the constant suffering, etc., cause rapid 
failure of the vital powers ; the flesh wastes, the skin appears earthy 
or jaundiced, the digestive functions are disordered in consequence of 
the absence of bile, and ascites may slowly accumulate. Death takes 
place by rupture and escape of the blood into the peritoneal cavity. 
In one case (Frerichs) blood was regurgitated by the stomach, and it 
reached this organ by a circuitous channel ; communication by a very 
small orifice was established between the sac of the aneurism and the 
gall-bladder, and a small quantity of blood continually passed from 
the gall-bladder to the duodenum, and thence by retching into the 
stomach. 

THROMBOSIS OF THE PORTAL VEIN is a result of various ob- 
structive conditions, as cirrhosis, chronic atrophy, cancer, and tumors. 
The symptoms due to the thrombosis are those of obstruction to the 
portal circulation, and occur rather abruptly in the course of the 
chronic malady associated with it. The pressure in the initial radi- 
cles of the portal vein is suddenly increased, and free transudation of 
blood occurs along the intestinal mucous membrane, hemorrhoids 
form, and a watery diarrhoea takes place. The spleen enlarges, and 
ascites develops with great rapidity. Efforts toward a compensatory 
circulation are made by the communicating veins, which suddenly 
appear enlarged on the surface of the abdomen. The urine becomes 
scanty and of high specific gravity. The patient presents a very de- 
cided cachexia, the strength rapidly fails, and death occurs in a few 
days or weeks. The obstruction by the thrombus is not always com- 
plete, so that an imperfect circulation is maintained. In that case 
the symptoms will be less formidable and the progress less rapid. 
The only remedy which offers any prospect of relief is ammonia, 
which has the power to dissolve coagula. Unfortunately, the stasia 



PYLEPHLEBITIS. 



209 



in the portal system so hinders absorption that remedies do not readily 
enter the blood. As Halfourd, of Australia, has demonstrated the 
innocuousness of the intravenous injection of ammonia, this expedient 
should be practiced in such cases. It consists in the injection of one 
part of aqua ammoniEe to two parts of water into any convenient vein. 
If, however, there be any movement of blood in the portal, the am- 
monia should be administered in the form of the carbonate — five 
grains every three hours. The usual remedies for ascites will be 
necessary. 

SUPPURATIVE INFLAMMATION OP THE PORTAL VEIN, or 
SUPPURATIVE PYLEPHLEBITIS. — This is always a secondary dis- 
ease, and has its origin in suppuration occurring at some point in the 
distribution of the portal vein. An inflammation occurs in the tunics 
of the vessel, which become soft and discolored by the presence of 
a fluid and fibrinous, purulent exudation, and by imbibition of the 
hsematine. The intima especially is discolored, brownish, yellowish, 
or greenish-yellow, and is covered with layers of fibrin and pus. The 
changes extend to and involve the adventitia. A thrombus forms in 
the vessel and undergoes characteristic alterations, softens in the cen- 
ter, becomes yellow, the fibrin breaking up into a granular mass, and 
the hsemoglobulin disintegrating and gradually forming, with the rest 
of the thrombus, a purulent-looking fluid. Thrombi form most fre- 
quently in the hepatic branches of the portal, and emboli in some cases 
are deposited in other parts of the liver, and secondary pyjemic abscesses 
occur in various parts of the body. 

Suppurative inflammation of the portal vein is associated with and 
is dependent upon ulcerations in various parts of the intestinal mucous 
membrane, or suppuration and abscesses in the mesenteric glands, or 
the inflammation and ulceration following impaction by gall-stones, 
etc. The symptoms, therefore, succeed to those of the malady which 
caused it. The initial symptom is pain, and it is felt in the umbilical 
region, in the iliac region, or in the hypochondrium, according to the 
branch of the portal implicated ; then follows a severe rigor, which, 
after a period of high temperature, terminates in a profuse sweat. 
These paroxysms, intermittent in type, are repeated, not in a regular 
order, but at uncertain intervals. In the interval the temperature is 
rather subnormal ; during the pyrexia the temperature rises to 105° or 
106° Fahr., and the sweats are most exhausting. The liver enlarges 
and is tender, and jaundice appears. The spleen also enlarges, doubt- 
less because of the obstruction in the portal circulation. Usually there 
is a profuse diarrhoea, the discharges consisting of a reddish, watery, 
and fetid fluid, sometimes of bilious matter. The abdomen becomes 
tender, and is much distended ; vomiting comes on ; the exhausting 
alvine discharges continue, and hence the powers of life rapidly decline. 
16 



210 



DISEASES OF THE LIVER. 



The secondary deposits excite local distress, and each addition to the 
area of suppuration increases the hectic fever. Deposits in the brain 
cause delirium and stupor, but, without these, low-muttering delirium 
comes on, with a typhoid state, and death occurs in a gradually deep- 
ening coma. The fatal result may occur in one week, or may be post- 
poned to six weeks— the average being about three. 

The diagnosis must always be a matter of extreme difficulty, and 
can, indeed, be made only when the cause is clear and all the symp- 
toms appear in their proper relation. It will be impossible in any 
doubtful case to differentiate between pylephlebitis and abscess of the 
liver. 

The treatment is without utility. While this is true, it is certain, 
however, that much may be done to relieve pain by the hypodermatic 
injection of morphia. It is in a high degree probable that large doses 
of quinia may be very serviceable in checking suppuration, and the 
free use of alcohol is certainly applicable in the same direction. The 
combination of morphia and quinia, with the conjoined administration 
of alcoholic stimulants, offers the best prospect of relief. 

DISEASES OF THE BILIARY PASSAGES: CATARRH OF THE 

BILE-DUCTS. 

Definition. — By catarrh of the bile-ducts is meant an inflammation 
of the mucous membrane, with an increased production of mucus. 
Very rarely there occurs a croupous inflammation, associated with 
infectious maladies, as pyaemia, diphtheria, etc. 

Cause. — Catarrh of the biliary passages may arise spontaneously 
from climatic causes or from malarial influence. It occurs, therefore, 
more frequently in the autumn, when cool nights succeed to warm 
days, and when malaria is most rife. Malaria may induce jaundice 
by catarrhal swelling of the bile-ducts, without any febrile disturb- 
ance.* Catarrh of the bile-ducts is usually a secondary disease, sec- 
ondary to duodenal or gastro-intestinal catarrh, which extends by con- 
tinuity of tissue up the bile-ducts. A variety of causes are concerned 
in the production of duodenal catarrh — notably, excesses in eating and 
drinking. Usually the attacks are excited by some article of food 
which especially disagrees, but a catarrhal state of a chronic kind has 
preceded the acute attack. 

Pathological Anatomy. — More or less extensive hyperaemia is the 
initial lesion. The common duct is more affected than any other part 
of the canal-system, but the catarrhal process may extend to and in- 
volve the canaliculi. The mucosa is swollen, the more decidedly near 
the duodenum, and is coated with a tenacious mucus, so that the 

* *' Des AflFections Paludeennes du Foie," par MM. A. Kelsch ct P. L. Kiener, " Arch, 
de Physiologic normale et pathologique," 18Y8, p. 671, et seq. 



CATARRH OF THE BILE-DUCTS. 



211 



lumen is much narrowed or obstructed. The mucous secretion of the 
gall-bladder is increased in amount and mixed with the bile, stored up 
more abundantly because the obstruction at the outlet existed while 
the hepatic and cystic ducts were still pervious. The viscid mucus 
and sero-mucus poured out from the surface of the membrane contain 
cast-off epithelium, abundant nuclei, and white corpuscles, and the 
endothelium itself undergoes proliferation. The obstruction below 
preventing the escape of bile, and the mucus and sero-mucus accumu- 
lating by continued production, the ducts above become dilated, and 
the tissue of the liver presents the usual appearance of bile-staining 
when there is a biliary stasis. After several days the hyperaemia less- 
ens, and a quantity of dead endothelium is cast off, still more effectu- 
ally blocking the passage ; but the contents of the bile-ducts gradually 
liquefy, and the lumen is restored to its former dimensions by the 
escape of these matters into the duodenum. Th e whole process will 
occupy several weeks. This fortunate solution of the catarrhal process 
is not always effected. The soft tissue of the liver-parenchyma is ex- 
ceedingly liable to degenerative changes. Recent researches (Charcot,* 
Legg t) have demonstrated that mere mechanical blocking of the com- 
mon duct leads in a short time to fibroid degeneration (increase of the 
connective tissue, interstitial hepatitis) and atrophy of the gland-cells. 
It has long been known that persistent attacks of catarrh, or the fre- 
quent repetition of them, will lead to changes in the parenchyma ; 
but these late investigations, by demonstrating the readiness with 
which pathological alterations occur in the hepatic parenchyma, have 
added much to the pathogenetic importance of catarrh of the bile- 
ducts. Rarely, isolated portions of the liver remain obstructed, and 
dilated ducts, surrounded by parenchyma deeply stained with bile and 
much altered, exist in patches throughout the organ. 

SymptOins. — The signs and symptoms indicating the onset of the 
malady are not the same for all forms. The form due to alternations 
of temperature at certain seasons commences abruptly with some pain, 
soreness, and sense of weight in the right hypochondrium ; constipa- 
tion exists, the tongue is coated, and the appetite absent ; and there 
are some feverishness and general malaise. There are also much de- 
pression of spirits and a feeling of illness, greater than the actual lesions 
warrant. In from three to five days the eyes become yellow, and 
icterus, or jaundice, then gradually appears over the whole body. 
Usually the fever disappears in two or three days, the skin becomes 
dry and harsh, and the surface cold. The pulse is slow, the action of 
the heart weak, and the strength depressed. When this form of jaun- 

* " Le9ons sur Ics Maladies du Foie, des Voies Biliaires et des Reins," Paris, 1877, 
p. 354. 

f " St. Bartholomew's HospitJ Reports," vol. ix ; various articles in the "British 
Medical Journal," etc. 



212 



DISEASES OF THE LIVER. 



dice is produced hj malarial infection, the synlptoms will develop 
more slowly, unless, indeed, the disturbance in the hepatic functions 
is accompanied by malarial fever — intermittent or remittent. The 
most usual determining cause of catarrhal jaundice is gastro-intesti- 
nal, especially duodenal, catarrh. In some subjects a chronic catarrh 
exists, and but little additional disturbance suffices to close the duct. 
In others an acute catarrh is brought on by some indigestible food or 
improper drink. In either case, the patient experiences a good deal of 
nausea, has a heavily coated tongue, headache, and a somewhat muddy 
complexion, and there may be more or less fever, or none at all. The 
jaundice does not appear at once ; there must be sufficient time for the 
extension to the bile-ducts to take place, which will require from one 
to two weeks. The bile-pigment tints all the tissues of the body, the 
secretions, and even pathological products, as effusions into the ven- 
tricles and thoracic cavity. The urine soon assumes a brownish color, 
like that of port or black coffee, and is heavily loaded with urates. 
Some drops of the urine placed on a w^hite porcelain surface, and a 
little nitric acid made to flow against it, will exhibit the following re- 
action at the margin where the two fluids come in contact : a greenish 
tint, quickly followed by blue, violet, to red. This play of colors may 
not be seen, but bilirubin, where touched by nitric acid, should take 
on a greenish hue, being converted to biliverdin. During the febrile 
stage, if fever has existed at all, the pulse rises ; but when jaundice 
appears, if no fever is present, the action of the heart is slowed and 
the tension of the vascular system lowered. The pulsations may de- 
cline so much as twenty or thirty to the minute. This depression of 
the circulation is due to the action of the biliary salts on the heart 
itself, for the same effect is produced when the pneumogastric has 
been previously divided. No bile passing into the intestine, certain 
substances fail to be digested, especially the fats, and the foods pres- 
ent there decompose, and a great quantity of fetid gas is formed. 
The results, then, of the absence of bile are white, pasty, or grayish- 
white, or gray, slate-colored stools, having a very offensive smell, and 
flatulence. The presence of bile in the skin excites in most persons a 
great deal of unpleasant itching, which may, indeed, be troublesome 
enough to prevent sleep. The vision is yellow from the presence of 
bile-pigment in the humors of the eye. The liver increases in size, 
and extends a little beyond the margin of the ribs, and the gall-blad- 
der is also sufficiently distended to be felt, in thin persons, projecting 
beyond the margin of the liver, or be made out by careful percussion. 
If the gall-bladder partakes in the inflammation, it becomes tender. 
Usually in from two to five days after the jaundice appears, the un. 
pleasant symptoms subside — the fever ceases, the tongue cleans, and 
the appetite returns, and only the jaundice and the torpid state of the 
intestines remain. In a few days the stools become darker and then 



CATARRH OF TOE BILE-DUCTS. 



213 



normal, the fetid odor disappearing at the same time. The coloration 
of the tissues and the pigment in the urine continue until the work 
of elimination is complete, and hence high-colored urine is the final 
symptom. 

Course, Duration, and Termination. — Cases pursuing the ordinary 
course, having the catarrhal period, the jaundice period, and the 
period of convalescence, last from three to six weeks, and terminate 
in complete recovery. Not all cases pursue this favorable course. 
The resolution may be postponed, and the case assume a chronic char- 
acter, leading to changes in the hepatic parenchyma, consisting in 
increase of the connective tissue and an atrophy, largely fatty, of the 
hepatic cells. The existence of a chronic catarrh of the duodenum 
invites attacks of acute catarrh involving the ducts, the result being 
the same — changes in the hepatic parenchyma. Catarrh of the bile- 
ducts becomes much more important from this point of view. 

Diagnosis. — At the beginning, catarrh of the biliary passages may 
be confounded with the initial symptoms of acute yellow atrophy, but 
the sex and the condition of pregnancy are so influential in causing 
the latter that we have in these etiological factors means of differ- 
entiating in two thirds of the cases. The subsequent behavior of the 
two maladies differs so widely as to eliminate all doubt. When the 
jaundice appears there is a possibility of confounding it with the jaun- 
dice which sometimes comes on in the course of cirrhosis and cancer, 
but an attentive examination of the course and history of each will 
prevent error. 

Tieatment. — This is one of the very few conditions in which mer- 
curials may be prescribed in hepatic diseases, not with the view to 
increase the outflow of bile, but to allay irritation of the mucous mem- 
brane. From -f^ to i grain of calomel, rubbed up with a little sugar, 
may be administered every four hours for a few days. Simultaneously, 
whether malaria is or is not an element in the case, two antipyretic 
doses of quinia (10 — 15 grains) should be given daily until jaundice 
appears, and for a few days subsequently to its full development. To 
maintain free action of the kidneys by salines is highly useful by favor- 
ing elimination. The ordinary effervescing powder, or the aperient 
effervescing powder, if constipation is decided, is well adapted to ac- 
complish the object. The Saratoga waters, or Vichy, or Kissengen, 
or Carlsbad, may be drunk freely to accomplish the same purpose. 
In the chronic cases, with persistent plugging of the bile-ducts, which 
means also persistent jaundice, the most effective remedy is sodium 
phosphate in 3 j doses ter in die, and kept up until the jaundice de- 
clines. This is also the most appropriate and effective remedy in 
those cases of chronic gastro-duodenal catarrh with occasional at- 
tacks of catarrhal jaundice. Recent experimental (Rutherford) and 
clinical experience has shown the value of euonymin and iridin as 



214 



DISEASES OF THE LIVER. 



cholagogues. Two grains of the former and four of the latter, given 
at night, and followed by a saline, afford excellent results. The min- 
eral acids were formerly held in great esteem in the treatment of these 
hepatic affections, but it is now known that alkalies are more service- 
able. The local application of the acid-bath to the right hypochon- 
drium is an excellent counter-irritant, but the difficulty experienced 
in preventing injury to the clothing is a strong objection to its use. 
Careful regulation of the diet is most necessary. Solid food should 
be withdrawn for the time being, and all fatty, saccharine, and starchy 
substances also, for these require the action of the bile either for their 
solution and absorption, or to prevent their decomposition. The most 
suitable aliments are skimmed milk and beef-juice. The former should 
be given freely every three hours, and, if the stomach is irritable, a 
little lime-water should be added. The utility of the milk is twofold 
— as an aliment and as a diuretic. Bitartrate-of-potassium lemonade 
is an excellent diuretic in these cases to remove the last staining of the 
bile. As the catarrhal inflammation subsides, the diet may be increased^ 
but it should consist of milk, eggs, fresh meat, fresh fish, and the suc- 
culent vegetables. 

OCCLUSION OF THE BILIARY PASSAGES. 

Causes. — The pressure of tumors, as cancer of the pancreas, aneurism 
of the hepatic artery, etc., is an exterior cause ; the impaction of a cal- 
culus, adhesion of opposed surfaces in exudative inflammation, etc., are 
internal causes of occlusion of the bile-ducts. 

Results of Occlusion. — The mucus formed all along the canals con- 
tributes somewhat to the accumulation of fluids when the outlet is 
closed, but the chief constituent is bile. The neck of the gall-bladder 
is not unfrequently closed by an impacted calculus, the sac becoming 
enormously distended with a transparent, faintly greenish fluid, result- 
ing from the transformation of the mucus and of the bile stored up 
before occlusion. The author has seen one example of occluded orifice 
of the cystic duct, in which the contents of the gall-bladder consisted 
of forty-four biliary calculi without any fluid. As the gall-bladder is 
an organ of convenience and not of necessity, its closure does not dis- 
turb the hepatic functions. It forms sometimes — for the secretion of 
mucus continues — a tumor of considerable size, and pyriform shape, 
which may be felt projecting from under the liver. Occlusion of the 
common duct (ductus choledochus) or of the hepatic duct leads to dila- 
tation of the biliary passages and to changes in the structure of the 
liver. The whole organ is at first enlarged, but it subsequently under- 
goes atrophy by the pressure, and death ultimately ensues from the 
blood-poisoning. 



BILIARY CALCULI. 



215 



BILIARY CALCULI (CHOLELITHIASIS— GALL-STONES). 

Causes. — In the normal state the bile does not contain any solid 
constituents. The formation of calculi or concretions is determined 
by the precipitation of a crystallizable substance from the bile — choles- 
terine — which is held in solution by glycocholate of soda. The mucus 
formed in catarrh of the biliary passages effects a decomposition of 
this compound. It is probable that this result is promoted by changes 
in the composition of the bile, and that the cholesterine may be in 
excess, and hence held feebly in its combination. Calculi form more 
frequently after than before the middle period of life, for then choles- 
terine becomes more abundant ; and they are encountered in the obese, 
in hearty feeders by preference, and in the sedentary. Females are 
more liable than males, especially fat women who eat rich food and 
take no exercise. 

Pathological Anatomy. — Cholesterine is the principal constituent 
of biliary calculi, and exists in the crystalline form chiefly. The ac- 
tual proportion of this constituent to the others is from seventy to 
eighty per cent. More or less bile-pigment enters into their formation ; 
also the carbonate of lime and earthy phosphates and carbonates ; and 
a particle of mucus or some foreign body is the nucleus about which 
the other materials crystallize or aggregate. Occasionally there is 
a single concretion of large size, which fills the gall-bladder, but usually 
they are very numerous — sometimes amounting to five or six hundred. 
When there is a single gall-stone it is ovoid or globular, to adapt it to 
the shape of the sac, but, when there are several, they assume the octa- 
hedral shape, with smooth facets. They do not always assume regular 
shapes : some are covered with warty masses ; others are leaf-shaped, 
etc. In color they are brownish or yellowish-brown, but in exceptional 
instances are found in all colors from white to black. They are very 
light, the specific gravity varying from 1'500 to 1*800.* Gall-stones 
usually contain a nucleus, composed for the most part of mucus, 
and cholesterine and bile-pigments are deposited in alternating, con- 
centric layers around it. The nucleus is not always in the center, 
and there may be several nuclei, and hence the arrangement of the 
layers is irregular, and there may be deposits of earthy matter and 
pigment, without cholesterine, etc. Gall-stones may be found in any 
part of the biliary passages. They are rare in the interior of the liver, 
and they are not often found in the hepatic duct, because of the in- 
creasing caliber below, but are found usually and in the largest num- 
bers in the gall-bladder. By pressure the walls are irritated and a 
catarrh is set up, and also ulcerations of the mucous membrane of con- 
siderable depth and extent are induced. The walls of the gall-bladder, 



* Thudiehum on " Gall-stones," p. 10. 



216 



DISEASES OF THE LIVER. 



excited to frequent expulsive efforts, undergo hypertrophy, and the mu- 
cous membrane becomes reticulated. Inflammation of the peritoneal 
investment is excited, and the remains of exudations and adhesions are 
usually found. Not unfrequently the mouth of the gall-bladder is oc- 
cluded by an impacted calculus, or permanently closed by inflamma- 
tory adhesions. The gall-stones may be forced down, producing pains 
in the passage through the cystic duct, or, the mouth of the gall-blad- 
der being closed, they remain and produce no further mischief. Gall- 
stones may become impacted in the cystic, hepatic, or common duct ; 
inflammation and ulceration, with perforation, result. 

Symptoms. — AVhen gall-stones are free in the biliary passages with- 
out obstructing them, they give rise to some pain in the right hypo- 
chondrium of an intermittent character, and pains radiating thence to 
the shoulder, umbilicus, lumbar region, etc. There is present usually 
nausea, even vomiting, and there may be chills, followed by fever and 
sweats. These symptoms are due to the irritation of the ducts, without 
their occlusion. If concretions are impacted in the hepatic duct, there 
are pains, jaundice, and enlargement of the liver. When calculi escape 
from the gall-bladder into the cystic duct, if of suflicient size to irritate 
the mucous membrane and excite spasm, the phenomena of hepatic colic 
ensue. Sometimes, after a fit of anger, or the receipt of evil tidings, but 
most frequently in about three hours after a meal, a pain of exceeding 
violence is suddenly felt at the margin of the liver and in the right por- 
tion of the epigastric region. The pain has a boring, burning, lanci- 
nating character, and radiates through the abdomen and chest and into 
the shoulders and back, but the situation of the greatest anguish is in 
the region of the gall-bladder. The pain is so atrocious that the 
patient writhes with the agony, rushes up and down the room, or tosses 
from side to side if in bed. The surface is cold and covered with a 
cold sweat, and often a severe rigor occurs simultaneously. There 
may be clonic spasms affecting the right side, or an epileptiform seiz- 
ure, with loss of consciousness, may occur. Intense nausea accompanies 
the pain. At first the food is thrown up, but presently, after repeated 
retching, only some mucus, acid and watery ; but the vomiting affords 
no relief. The action of the heart is feeble, and the circulation is cor- 
respondingly depressed. The severity of the seizure is influenced by a 
variety of circumstances — by the size and roughness of the concretion, 
by the length of canal to be traversed, and by the condition of the 
nervous system. The duration of the seizure varies from a few hours 
to several days, and the first attack is apt to be more severe than any 
succeeding one. When the attack continues for several days, the pain 
docs not always persist even for hours, for there are remissions in which 
only an acute soreness remains, and the exacerbations behave as regular 
attacks. It is highly probable that in these cases several concretions 
are passed in succession. Again, when the calculus passes from the 



BILIARY CALCULI. 



217 



cystic to the common duct, there is a feeling of relief, but a new par- 
oxysm occurs when the calculus becomes engaged in the duodenal ori- 
fice of the ductus choledochus. Inflammation in the peritoneum may 
be excited about the site of impaction, and involve the neighboring 
structures, or the duct may become gangrenous. The calculus, by 
preventing the outflow of bile in the hepatic or common duct, causes 
jaundice, which is not a usual symptom in impaction of the cystic duct ; 
although it may be present, the surrounding swelling being sufiicient 
to prevent the flow of bile through the common duct, or it is probable 
that jaundice may be due to the disturbance in the hepatic plexus of 
nerves. The pain suddenly ceases sometimes by the dropping of the 
concretion into the duodenum. Jaundice usually succeeds to the pain, 
and is not often seen during the time of greatest suffering. Sometimes 
a calculus will remain impacted in the common duct for weeks or even 
months ; jaundice persists, the bile accumulates, the ducts dilate, until 
suddenly the impaction is overcome, and violent bilious vomiting and 
diarrhoea announce the delivery. When the concretion remains per- 
manently impacted, the liver undergoes the changes already noted ; the 
connective tissue multiplies, the gland-cells waste and undergo fatty 
metamorphosis, and the organ shrinks in size (Charcot). Careful search 
should always be made in the evacuations for the calculus. The fteces 
should be thoroughly mixed with water, the solid particles allowed to 
subside and the fluid portion poured off, and this operation must be 
repeated until the last solid parts are reached. Sometimes — most 
frequently, probably— there is but one calculus, but there may be a 
hundred. A marvelous change takes place in the patient as soon as 
the calculus reaches the intestine. The pain ceases, as well as the nau- 
sea and vomiting, the bowels act spontaneously, the appetite returns, 
the jaundice soon disappears, and the state of health is fully restored. 

Course, Duration, and Termination. — From the initial pain to the 
termination of all symptoms may not be longer than two days, or, if 
jaundice is present, five days. If a number of calculi pass, the duration 
of a case is indefinitely prolonged. The severe cases of this kind last 
several weeks. The usual termination is in health, but death from 
ulcerative perforation and subsequent peritonitis is not uncommon. 
Now and then a calculus ulcerates through the duct ; in the peritonitis 
which follows, adhesions are formed, limiting the mischief to the im- 
mediate neighborhood ; a purulent depot is thus created, and gradually 
a fistulous communication externally is established, and the calculus 
is discharged with the pus. Sometimes such a purulent depot opens 
communication with the intestine, stomach, or bladder. The last- 
named terminates fatally ; the discharge by the stomach, intestine, and 
externally is often successful. After the calculus reaches the intestinal 
canal, it may serve as a source of new mischief by forming the nucleus 
of an impaction of the bowel. 



218 



DISEASES OF THE LIVER. 



Diagnosis. — The only maladies with which hepatic colic may be 
confounded are hepatalgia, gastralgia, and enteralgia. The locality of 
the pain, the absence of local soreness, the absence of jaundice, the 
absence of calculi in the stools, separate these neuralgic affections from 
hepatic colic. 

Prognosis. — A favorable opinion may be expressed in most cases, 
but the prognosis must be guarded when the pain does not yield, and 
when the vital powers begin to flag, especially if local tenderness and 
fever indicate peritonitis. 

Treatment. — The severe pain demands immediate attention. There 
are two methods of relieving it : by the inhalation of ether, and by 
the hypodermatic injection of morphine. The action of the former is 
temporary, and, of course, the relief is confined to the period of un- 
consciousness. This may be sufficient, but usually prolonged adminis- 
tration is necessary. The hypodermatic injection is more effective. 
From to ^ of a grain of morphine is usually sufficient for an ordinary 
case, but, if the suffering be very great, J to J grain of morphine may 
be required. The combination of morphine and atropine is both more 
effective and safer, and hence atropine should be given, yi-g- grain at 
each injection. Not only does this remedy remove the pain, but it is 
the most efficient means of preventing or subduing peritoneal inflam- 
mation. Anodynes can not be given by the stomach ; anodyne ene- 
mata are insufficient in this malady — so that the choice of remedies 
is much restricted. Five minims of chloroform every half hour, in 
an emulsion or dropped on sugar, has been proposed, but in the au- 
thor's experience it is usually rejected, and excites nausea even by 
its odor. It has been gravely proposed to administer it as a solvent 
of gall-stones, and to relieve the suffering by effecting a solution of 
the impacted calculus. Trousseau had, it was supposed, disposed 
of this notion, but it has been revived again. Chloral has also been 
employed to relieve the pain, but it is very offensive to the stomach ; 
yet, if given by the rectum, it is highly efficient in relieving the 
pain by allaying spasm, and also, probably, has some solvent action. 
Warm baths and hot fomentations to the right hypochondrium con- 
tribute to relief. Undoubted advantage is derived from the use of 
leeches, when, the symptoms persisting, tenderness develops and fever 
arises. 

Prophylaxis is highly important. The author has had abundant 
and highly favorable experience with the plan which is about to be 
recommended, and he therefore urges it on the attention of his readers : 
The diet must be carefully regulated. All fats and articles containing 
fat in any form are rigorously excluded. Saccharine substances are 
also prohibited, and the starchy constituents of the diet are reduced to 
a little white or corn bread — potatoes, beans, peas, and rice being ex- 
cluded. Lean meat of all kinds, eggs, fish, fruit, and the succulent 



BILIARY CALCULI. 



219 



vegetables are permitted freely. Wine at dinner is allowed, but malt 
liquors and spirits are forbidden. Daily exercise is directed. All 
irregularities of life of every kind are given up. The most effective 
remedy for the removal of the conditions which lead to the formation 
of biliary calculi, or to bring about their solution, is sodium phosphate. 
This is prescribed in the dose of a drachm three times a day, dissolved 
in sufficient hot water, and taken before meals. This remedy is con- 
tinued for several weeks or months, and, if there are present evidences 
of gastro-intestinal catarrh, -g^ of a grain of the arseniate of soda is 
added to each dose of the phosphate. While success seems always to 
attend this practice, the author has been constantly disappointed in the 
remedy of Durande (ether and turpentine), and in the administration 
of chloroform, with a view to its solvent action on retained calculi. 
As the catarrhal state of the bile-ducts, succeeding to catarrh of the 
duodenum, is the great factor in the causation of gall-stones, it is 
highly important to correct it. Without attention to the plan of diet 
above indicated this can not be accomplished ; but the persistent use 
of phosphate of soda can do much, even without a change in the habits 
of life, toward bringing about a cure. Yichy-water, and our own Sara- 
toga Vichy, as well as the alkaline waters of this country, which are so 
abundant, should be used daily in connection with the plan above indi- 
cated. Dr. T. H. Buckler, of Baltimore, strongly recommends the use 
of the hydrated succinate of the peroxide of iron ( 1 jss — § vjss water 
— a teaspoonful ter in die) as a remedy to prevent the formation of 
calculi. The use of this remedy is based on some theoretical notions 
respecting the oxidizing power of succinic acid and its solvent action. 
Buckler also urges the use of chloroform during the paroxysms of 
colic, as a solvent of cholesterin. Harley advocates the use of sul- 
phate of soda. Cholate of soda — a constituent of normal bile — theo- 
retically an appropriate remedy, has been lately given with success, 
in doses of from two to five grains. 



220 



DISEASES OF THE SPLEEN. 



DISEASES OE THE SPLEEN". 



TOPOGRAPHY OF THE SPLEEN. 

In the normal condition of tlie organ the spleen is too small and 
too deeply placed to be felt, or indeed to be defined, even by careful 
percussion. Lying under the concavity of the diaphragm, covered by 
the stomach and by the transverse colon, and surrounded by the ribs, 
it is not brought within the range of our clinical methods. It is liable 
to displacement, the vessels forming a pedicle of less or greater length, 
permitting sometimes an extensive range of motion. Under such cir- 
cumstances, instead of its natural position in the left hypochondrium, 
the spleen may glide downward into the umbilical, even as low as the 
hypogastric region. When enlarging from its true position in the 
hypochondrium, the change consists in an expansion, obliquely down- 
ward, of the area of splenic dullness. 

The size and density of the spleen may be ascertained with an ap- 
proximation to accuracy, by percussing the organ when forced down- 
ward and held by a full, retained inspiration, and comparison with the 
same area emptied by a full expiration. 

The spleen being a highly elastic body, and its dimensions varying 
with the amount of blood contained in the vessels, there are rapid 
changes in the area of splenic dullness, strictly within physiological 
limits. Certain remedies, as ergot and quinine, have the power to con- 
tract the organ, but it is probable that this action only takes place 
when the spleen has undergone a pathological enlargement. 

ACUTE SPLENITIS. 

Definition. — By the term acute splenitis is meant acute inflammation 
of the spleen. Perisplenitis is a designation applied to inflammation of 
the investing tunic or capsule, and of the peritoneal layer of the organ. 
Acute splenic tumor means an acute enlargement — a condition present 
in various acute infectious diseases. 

Causes. — Our present know^ledge of the etiology of spleen-diseases 
is very unsatisfactory. Hardly anything is known of idiopathic sple- 
nitis. Of the secondary, or metastatic malady, our information, if not 
full, at least contains some certain data. That splenitis arises from 



ACUTE SPLENITIS. 



221 



embolism is now well known. Inflammation of neighboring parts ex- 
tends to and involves the spleen. Direct injurj^, as a blow over the 
left hypochondrium, may excite inflammation in the spleen. A case 
arising in this way the author had under observation during life, and 
was present at the autopsy ; hence the account given of the disease 
in question is derived largely from this experience. 

Pathological Anatomy. — Local, or circumscribed, splenitis is in- 
duced by embolic blocking of a vessel or vessels, and hence the infarc- 
tions may be one, or two, or three in number ; they may be in the sub- 
stance, or at the periphery of the organ."^ These infarctions vary in 
size from a pea to a hen's-egg, are wedge-shaped, and when near to- 
gether may coalesce. These infarctions undergo the usual transfor- 
mation, and a purulent collection is the ultimate result of the changes. 
A limiting membrane may form, and the pus become encapsulated, or 
the boundaries of the purulent depot may be constituted of the rag- 
ged, disintegrating, soft, splenic pulp. The pus tends to make its way 
externally, and when the capsule is reached adhesions fonn, usually to 
the diaphragm. In the author's case, as a result of a powerful blow 
on the left hypochondrium (which, however, left no external trace of 
the injury), the whole organ was turned into a brownish purulent col- 
lection of eighteen ounces' capacity. Adhesions had been formed with 
the diaphragm, which was softening, and adhesion of the opposed 
pleural surfaces indicated the preparation for discharge by a bronchus. 
The abscess may break into the peritoneal cavity, with the effect of 
inducing fatal peritonitis. 

Symptoms. — As the systematic writers are not agreed as to the 
character of the symptomatology, the author describes it wholly from 
his own observation. After the injury, or we may also suppose the 
embolic obstruction, in a day or two, pain is experienced, deeply in 
the right hypochondrium. The sensation is rather of an aching char- 
acter, which becomes soreness and tenderness when the organ is com- 
pressed — a feat that is accomplished by pressing upward under the 
ribs when the patient takes a full inspiration. There is usually pain 
developed by taking a deep breath, which becomes catching and acute 
when the peritoneum is invaded. Neither on palpation nor on per- 
cussion can an increase in the volume of the spleen be made out with 
certainty. In about a week after the initial symptoms, a rigor oc- 
curred, followed by fever and sweats, and these appeared irregularly 
up to the end. The face was pallid, the lips white, the sclerotic glis- 
tening, the body emaciated, and the weakness extreme. The appetite 
was lost, there was occasional vomiting, and diarrhoea supervened 
toward the termination of the case. Presently a harassing, dry cough, 
accompanied with pain and an obstinate hiccough, made its appear- 

* Billroth ; Virchow's " Archiv," Band xxiii, p. 473 : " Der haemorrhagische Infarkt 
und seine Mctamorphosen." 



222 



DISEASES OF THE SPLEEN. 



ance. An increase in the left side through the hypochondrium and 
an enlargement of the area of splenic dullness now became evident. 
Death occurred by exhaustion on the forty-second day from the first 
symptoms. 

Course, Duration, and Termination.— Nothing can be more ill-de- 
fined than the course of splenitis. The duration of cases of inflamma- 
tion terminating in abscess may be not more than a month, and yet 
cases have continued several years (Hosier). Splenitis may terminate 
in resolution without symptoms. This is the most probable explana- 
tion of the existence of cicatricial depressions on the surface of the 
spleen, found in cases dying from other causes. Cases proceeding to 
suppuration terminate by discharge through the lungs, of which a 
successful case has been reported, or communication is established 
with the stomach, the transverse colon, the left kidney, or with the 
general cavity of the abdomen. 

Diagnosis. — If endocardial lesions exist, and sudden pain followed 
by swelling occur in the splenic region, and subsequently there arise 
the usual symptoms of suppuration, or if, as a result of a blow, pain 
and tenderness and swelling develop in the left hypochondrium, the 
spleen may be presumed to be the seat of the mischief. 

Prognosis. — As those cases of splenitis which terminate in recovery 
are never recognized, the question of prognosis does not come up for 
solution. When abscess occurs, the prognosis is unfavorable. 

Treatment. — If the existence of splenitis, from any cause, is as- 
certained, quinia must be freely administered, and cinchonism main- 
tained. There are two good reasons for this practice : quinia checks 
the migration of the white corpuscles and the process of suppuration, 
and lessens hypersemia of the spleen. No therapeutical fact is better 
established than that quinia reduces the size of the spleen when it is 
enlarged by hyperaemia. Quinia is, therefore, peculiarly adapted to 
the treatment of splenitis. Purgatives act on the spleen in two modes ; 
by reflex action, and by diminishing the general blood-pressure. Sa- 
line cathartics should be used to maintain free action of the intestines. 
Warm fomentations, turpentine-stupes, and hot poultices should be 
applied over the left hypochondrium. If suppuration is clearly ascer- 
tained, the aspirator should be used without delay, just as it is now 
employed in a similar state of things in the liver. The strength must 
be kept up by suitable food and stimulants. 

ENLARGEMENT OF THE SPLEEN.— Owing to its peculiar ana- 
tomical structure, the spleen is especially liable to variations in size, 
strictly within physiological limits. In the acute infectious maladies 
the organ undergoes a change in size of a pathological character. In 
typhus, typhoid, puerperal, and the eruptive fevers, the spleen en- 
larges, but in the fevers of marsh-miasm the change in size is greater. 



MISPLACEMENT OF THE SPLEEN. 



223 



In certain parts of this country — the Wabash Valley, for example — a 
splenic tumor of extraordinary size (ague-cake) sometimes develops 
under the influence of malaria without the objective phenomena of 
fever, but with the same bodily changes as occur in intermittent and 
remittent fevers. Obstructive diseases of the heart, lungs, or liver, by 
causing stasis in the venous system, give rise to enlargement of the 
spleen, and especially does this result follow sclerosis, and acute yel- 
low atrophy of the liver. In the condition of enlargement which occurs 
during the course of fevers — excepting from consideration malarial 
fevers — the spleen is excessively soft, the splenic pulp almost diffluent, 
the capsule and trabecula? easily torn. In the acute enlargement which 
accompanies the febrile movement of malarial fevers, there is really no 
alteration of structure — the pulp and trabeculae and the Malpighian 
bodies having their normal appearance and structure, but the increase 
is due to an immense venous congestion. On the other hand, in the 
enlargement which occurs without fever, or produced after successive at- 
tacks of fever, the organ is dense, firm, and paler, due to the great devel- 
opment of the trabeculse and corresponding diminution of the splenic 
pulp. In these cases of chronic enlargement due to malarial infection, 
the organ may attain considerable size, greatly distend the abdomen, 
and reach to and even extend beyond the umbilicus. There is in 
these cases an extreme anaemia — a pseudo-leukemia — the superficial 
veins of the abdomen are enlarged, the legs are swollen, and there is 
some effusion in the abdomen — results of the mechanical pressure. A 
splenic tumor of medium size, formed in the mode above indicated, 
may lodge on the aorta and be confounded with aneurism. 

MISPLACEMENT OF THE SPLEEN, or MOVABLE SPLEEN.— 

Changes in the position of the spleen are effected by effusions in the 
left thoracic cavity, which displace the organ downward. When en- 
larged and in the condition of "fleshy spleen" above described, the 
spleen may descend considerably by its own weight, and thus seem 
more enlarged than it is really. The movable spleen, like the movable 
kidney, is displaced from its position, and its vessels with the omen- 
tum are stretched and ultimately assume the shape of a pedicle — an 
irregularly rounded cord — of which the author has seen several capital 
examples. Such a spleen may be moved by a change in the position of 
the patient, or by palpation, and may lie across the abdominal artery 
and be lifted up synchronously with the arterial pulsation, or be dis- 
placed downward into the iliac fossa, and may rotate on its horizontal 
axis. Changes in the structure of the organ necessarily occur under 
these circumstances ; the blood-supply is lessened, or thromboses form 
in the vessels ; there are shriveling and atrophy, pigmentary and fatty 
degeneration, etc. 



224 



DISEASES OF THE SPLEEN. 



AMYLOID DEGENERATION OF THE SPLEEN.— This disease con- 
sists in the deposits of the amyloid matter, either in the form of small 
patches, forming the well-known sago-spleen," or in a general diffu- 
sion of the material through the whole organ. In the former the 
patches may be very numerous and almost unite, but there still remains 
normal spleen-tissue between them. In the latter form the texture of 
the spleen is firm and tough, but easily divided with the knife, although 
not readily broken up into a pulp, and it has a brownish or yellowish- 
brown color, and no part remains untouched by the new deposit — 
the pulp, the trabecules, the Malpighian bodies, the vessels, all are 
changed in structure and physical properties by the amyloid matter. 
The test for this matter is iodine — Lugol's solution — which when 
brushed over colors the tissues yellowish, but the amyloid matter red 
or reddish brown : now, on the addition of sulphuric acid, while the 
yellowish parts remain yellow, the amyloid becomes a dark violet. • 
The amyloid, or lardaceous, or waxy degeneration of the spleen 
occurs, simultaneously with the same form of degeneration in the 
liver and intestinal canal, and hence the symptomatology is rather 
that of the disturbance in the function of the other organs. These 
symptoms have been detailed in the remarks on amyloid liver. The 
only contribution made to the symptomatology by the alterations in 
the spleen are, the increased area of splenic dullness and a greater 
degree of aniemia and pseudo-leukemia. The great cause of amyloid 
degeneration of the spleen as of other organs is suppuration, espe- 
cially protracted suppuration in connection with bone. Next to this 
are the syphilitic cachexia and inherited syphilis. Chronic alcoholism 
and chronic malarial poisoning are supposed to have some influence in 
its production, but it is extremely doubtful whether they have any real 
influence. 

ECHINOCOCOUS OF THE SPLEEN.— The embryo of the taenia 
echinococcus is deposited in the spleen as in other organs, and more 
frequently in the spleen than in any, except probably the liver. The 
liver is reached readily by the portal vein, and the spleen directly, as 
the two organs come into contact. When established in its home, 
growth begins, chiefly by the development of daughter-vesicles in the 
mother-sac. The symptoms produced are due to the size to which the 
sac attains, the pressure on neighboring organs, and the interference 
with the circulation in the great vessels of the abdomen. The slow- 
ness of the growth, the absence of constitutional disturbance, the free- 
dom from pain, and the absence of symptoms except those due to the 
size of the tumor, separate the echinococcus from other tumors of the 
spleen. The sense of fluctuation, and especially the purring tremor, 
serves to distinguish this from hypertrophy of the spleen. The emplo)^- 
ment of the aspirator-needle will contribute to certainty of diagnosis. 



THE BLOOD. 225 

but the presence of booklets and tbe absence of albumen can not 
always be depended on, for tbe booklets may be absent, and albumen 
may be present in ecbinococcus tumors of tbe spleen. For further de- 
tails the reader is referred to the subject of ecbinococcus of the liver. 



DISEASES OF THE BLOOD-EORMINQ OEGANS. 



THE BLOOD. 

It will facilitate the comprehension of the maladies treated of in 
this section, to precede the account of the several morbid states with 
some observations on the nature and composition of the blood. 

Composition. — The ultimate chemical composition of the blood is 



as follows : * 

Reaction alkaline 

Specific gravity, from 1,045 to 1,0^5 

Water 781-6 

Globules 135- 

Albumen 10' 

Fibrin 2 5 

Fats 1-5 

Extractive matters 2*4 

Salts 6-5 

Iron *5 



The results of chemists vary according to the method of analysis 
employed. The most considerable departure from the ordinary method 
is that of Flint, who tries to measure the several constituents in their 
natural state ; that is, with their water of composition and the inor- 
ganic salts so closely associated with them as to be separated only by 
incineration. f There is much to be said in favor of this method. With- 
out engaging in this discussion, the several constituents of the blood will 
be briefly considered, with reference to the changes induced by disease. 

In general terms, the blood may be considered as made up of cer- 
tain morphotic or formed constituents — the corpuscles, red and white 
— floating in a complex fluid, containing, dissolved in it, albumen, fibrin, 
fats, and salts. The red corpuscle consists of two parts : the matrix, 
or stroma, which seems only to serve the purpose of a vehicle for its 

* Becquerel et Rodier. " Traite de Chimie Pathologique Appliquee k la Medeciue 
Pratique," etc. 

t The "Physiology of Man," vol. i, p. 133. 
17 



226 



DISEASES OF THE BLOOD-FORMING ORGANS. 



active constituent, the hcBmoglohin, the other part. The most impor- 
tant function of haemoglobin is its power to form compounds with 
gases of a very unstable nature, the chief being the combination with 
oxygen, oxy-hcemoglobin, or oxide-hcemoglohin. The oxygen is read- 
ily taken up and as readily parted with, this process constituting the 
so-called ozonizing or respiratory function of the blood. The arterial 
blood contains 16'9 per cent, in volume of oxygen ; whereas the ve- 
nous blood only has 5*96 per cent. Now, as this process of oxidation 
and deoxidation of the hsemoglobin goes on incessantly, the importance 
of the function is obvious. Haemoglobin is soluble in water, and crys- 
tallizes from its solution in fine crystals, called " blood-crystals." 

The white corpuscles, leucocytes, contain a good deal of protoplasm, 
and are closely allied to lymph and pus-corpuscles. They are derived 
from the lymphatic glands and lymph, and have a power of motion, 
which is called amoeboid, in virtue of which they may migrate from 
the vessels into the surrounding textures. 

The relative proportion of red and white corpuscles varies consid- 
erably within physiological limits. The average of the red corpuscles 
is in the proportion of five millions in a cubic millimetre of blood, and 
the white bears the proportion to the red of one to 800, and after a 
meal of one to 300 or 400. These figures must be regarded as merel}' 
approximative. The red corpuscles " constitute about one third of the 
weight of the blood, and contain about 43 per cent, of solids, and 39 
per cent, of haemoglobin " (Burdon-Sanderson). 

The fluid in which the corpuscles are suspended is the plasma. 
Serum is the plasma which has lost its plasmin by coagulation. When 
blood is allowed to stand under suitable conditions, it separates into 
corpuscles and plasma. At ordinary temperature, plasma coagulates, 
and a clot forms, composed of fibrin, with the corpuscles entangled in 
its meshes. This fibrin-clot when in its dissolved state is plasmin. 
The coagulation of blood consists in the solidification in delicate fila- 
ments of the plasmin, which when it assumes this form becomes fibrin. 
Besides plasmin, which is an albuminous substance, there are two albu- 
mens in plasma — ordinary albumen, and a small quantity of alkali-albu- 
men. The serum, and coagulable liquids generally, contain paraglohu- 
lin and fibrinogen^ but the action of a third substance is necessary to 
coagulation. This is a ferment^ now supposed to be produced by the 
white corpuscles. When these substances are present, spontaneous 
coagulation will take place. 

Blood plasma contains, also, 0*5 per cent, of the solid salts of the 
blood, consisting, for the most part, of sodic chloride, sodic phosphate, 
and sodic carbonates (chloride, phosphate, and carbonate of sodium). 

Examination of the Blood. — Apply a suitable ligature to the finger, 
make a puncture with a lancet, and receive a drop of blood on a per- 
fectly clean glass slide warmed to 100° Fahr. ; cover at once with thin 



THE BLOOD. 



227 



glass, which has been moistened by breathing on, and gently press it 
down until there is a stratum of blood so thin as hardly to appear red. 
It can now, and as quickly as possible, be examined with a quarter-inch 
objective. The red globules are particularly well seen with the binoc- 
ular of Beck. The condition of the red corpuscles, of the white, and 
their relative numbers, should be noted. The action of a reagent may 
be watched by bringing it to the margin of the cover-glass, when it 
will gradually dilfuse into the blood. Besides the ordinary constitu- 
ents of the blood, there may be seen, under peculiar circumstances, 
certain parasites, pigment granules and cells, crystals of uric acid, etc. 

The Hsemacytometer. — This instrument, as its name indicates, is 
intended to ascertain the number of blood-corpuscles. Devised in a 
crude form by Yierordt, afterward improved by Melassez and Hayem, 
the most convenient arrangement has been perfected by Gowers, and 
made by Hawksley, of London. The process of counting the corpus- 
cles by means of the hsemacytometer consists essentially in dilution 
of the blood to a definite degree, and numbering the corpuscles con- 
tained in a cell of given depth on a slide marked with ruled lines which 
indicate the lateral dimensions of the dilution. In this way quite a 
close approximation to the true number of cells in a given measure of 
blood can be made. The morbid conditions of the blood to the diag- 
nosis of which this method is applicable will be considered further on. 

The Haemoglobinometer. — The peculiar function of haemoglobin is 
so essential to the work of the body that means for ascertaining its 
quantity are very desirable. The haemoglobinometer is an instrument 
by which the proportion of haemoglobin in the blood may be deter- 
mined. Melassez and Hayem first demonstrated practicable methods, 
but the profession is here again indebted to the practical skill of Gow- 
ers for the perfection of an available apparatus. It consists, first, of a 
standardized solution of glycerin- jelly, colored to the tint of normal 
blood, and contained in a tube of given capacity ; second, of a tube of 
the same capacity as the first, for the diluted blood under examination. 
The degree of dilution necessary to make the blood-tint correspond in 
depth to the standard indicates the proportion of haemoglobin. Less 
accurate but more ready methods for approximating to the proportion 
of the blood coloring-matter are given in the section on hmmoglohi- 
nuria. 

Pathological Relations of the Blood. — Before entering on the sub- 
ject of the special pathology of the blood, it will be useful to indicate 
in outline the modes in which the blood is changed. The several 
raorphotic elements may be altered quantitatively and qualitatively, 
and the constituents of the plasma may be increased or diminished, or 
entirely removed. 

The red corpuscles of the blood diminish in number, and that to an 
extreme degree, so that the normal proportion of red and white may 



228 



DISEASES OF THE BLOOD-FORMING ORGANS. 



be reversed. Alterations in the shape of the corpuscles sometimes 
take place, but they have no precise signification, and have not thus 
far been studied with success. In the process of coagulation, the red 
corpuscles may not exhibit the normal behavior, and unite in rouleaux, 
but rather adhere in irregular masses. The significance of such a con- 
dition is not understood. New forms of corpuscles may appear, some 
of them transitional between the white and red. 

The blood may assume the appearance known as " lake," and be- 
come transparent instead of opaque. Such a change as the term lake 
supposes, indicates disorganization of the red corpuscles, and the sepa- 
ration of the coloring matter, which dissolves in the plasma. Various 
changes of color may take place. The transformation of venous into 
arterial blood may not occur, and the whole mass of the blood con- 
tinue of the venous hue. It may assume a chocolate tint, from the 
action of certain medicaments. 

The plasma of the blood may be variously altered. The relative 
amount of water may be increased or diminished, or, as it should 
rather be stated, the proportion of solids is increased or diminished. 
This change may be effected by some medicaments, but is most pro- 
nounced in certain morbid states ; for example, in the algid stage of 
cholera, when the loss of water from the blood, and its artificial replace- 
ment by intravenous injection, make a wonderful change in the 
condition of the subject. Variations in the proportion of albumens in 
the blood are caused by activity in the function of nutrition, and 
excess in the processes of waste and excretion. When albuminous 
foods are abundant, digestion active, and absorption prompt, the blood 
may contain relatively more albumen, but the excess above the needs 
of the organism will be deposited as fat, or excreted as uric acid and 
urea. Under some circumstances fibrin may be in greater than normal 
quantity, constituting the condition of hyperinosis, in which the coagu- 
lation of the blood is more prompt, and the clot firmer. Formerly the 
" buffy coat " was supposed to be indicative of hyperinosis, but this 
appearance is now known to be due rather to the condition of the red 
corpuscles, and their manner of settling in the process of coagulation. 

The salts of the blood are subject to considerable variation under 
conditions not now understood. Salts of potassium base are contained 
in the corpuscles chiefly, while those of sodium base are to be found 
in the plasma. The normal reaction of the blood, which is alkaline, 
may be changed to neutral, even to acid, by chemical transformations 
in the salts. 

The quantity of fat in the blood varies considerably within physio- 
logical limits. A diet rich in fat, the use of alcohol, obesity, tend to 
increase the proportion of fat in the plasma. The serum of the blood 
may, indeed, present a milky appearance in consequence of an excess 
in the number of fat-globules which have entered the vessels, and fat- 



LEUCOCYTHEMIA. 



229 



embolisms are caused by the admission of fat-cells into torn vessels in 
some cases of fracture of bones. 

Urea and uric acid are found in the blood in small quantity quite 
constantly, but in certain morbid states in excessive amounts. Crys- 
talline forms of urate of soda may, in some cases of gout, be detected 
in the serum. Leucin, tyrosin, acetone, and bile - pigment are also 
constituents of the blood, to be found during the existence of certain 
morbid states. 

To an expert the examination of a drop of blood is a comparatively 
easy task. It is only rarely that such an examination is necessary, 
when the indispensable skill is available. There is reason to fear that 
the routine examination of the blood, now so much spoken of, is rather 
intended to impress the patient than increase the knowledge of the 
conditions present. 

LEUCOOYTHEMIA— LEUO.EIMIA. 

Definition. — The terms leucaemia and leucocythemia were proposed 
by rival claimants for priority of discovery — Yirchow and Hughes 
Bennett. The term leucocythemia, proposed by Bennett, seems to the 
author a more correct designation, meaning white-cell hlood, than Yir- 
chow's leucaemia, which means white hlood. The morbid change which 
has given the name to the disease is the enormous increase of the white 
corpuscles of the blood, accompanied by enlarged spleen and enlarged 
lymphatic glands, and by alterations in the marrow of bones. By 
Trousseau it is designated adenie, and by Griesinger ancemia splenica. 

Causes.— The excessive production of leucocytes, which is the chief 
element in this disease, must necessarily be due to a functional and 
nutritive irritation of the blood-making organs. The evidence of this 
is afforded in the enlargement of the spleen and lymphatic glands. 
But the cause of this remains unknown, and hence the real nature of 
the malady continues an insoluble problem. Leucocythemia occurs 
at all ages and under every kind of social circumstance, but it attacks 
by preference the male sex, the most vigorous period of life — thirty 
to forty-five — and those who have been weakened by hardships and 
excesses. Menstrual irregularities have been supposed to have an 
influence in developing it, and, in twenty-one cases of this disease oc- 
curring in women, there were sixteen in whom some disorders of the 
uterus had existed (Mosler). It is probable that these sexual irregu- 
larities were rather coincident than causal. The cachexiae of chronic 
malarial poisoning and of syphilitic infection have been invoked to 
account for its production, but no satisfactory data have as yet been 
published, although there are examples of accidental association. Re- 
garded from the analogical point of view, leucocythemia may be 
classed with scrofula, cancer, tubercle, and other infectious diseases, 



230 



DISEASES OF THE BLOOD-FORMING ORGANS. 



which, beginning at one point, or focus, diffuse thence over the body. 
The morbid alterations characteristic of this disease begin in the 
spleen, then attack the lymphatic glands, then the marrow of bones, 
and thus become general. 

Morbid Anatomy. — The most constant lesion is in the spleen, which 
is increased in size, either uniformly, its form and shape being pre- 
served, or some part of the organ undergoes the change. Not only 
the size but the firmness and density are increased. The color be- 
comes a reddish blue ; the pulp undergoes hypertrophy, but the nor- 
mal relations of its elements are preserved ; the trabecule may be 
more distinct, or may be obscured by the overgrown pulp ; the Mal- 
pighian bodies are rather increased in number, very distinct, but less 
consistent than normal. The trabeculse and pulp may be coated with 
a yellowish, fibrinous exudation ; there may be seen white granules 
disseminated throughout the organ, and near the surface patches of 
indurated tissue, the remains of hemorrhagic infarctions. The change 
in the lymphatics consists in an initial hypersemia, then hyperplasia 
of its constituent parts, first of the cellular elements, then of the stro- 
ma and vessels. They enlarge in proportion to the addition of new 
material, from a bird's egg to a goose-egg or larger. They have a 
smooth, rather glistening, appearance, and to the touch are soft, non- 
elastic, and sometimes fluctuating. All of the lymphatic glands in the 
body may be engaged, or the process may be confined to a few. 
Usually those situated about the hilus of the liver and spleen are en- 
larged. Similar changes take place in the lymphatics of the digestive 
tract, beginning in the follicles of the tongue and tonsils, of the stom- 
ach, and in the glands of Peyer. Corresponding changes occur in the 
marrow of long bones, and in the cancellated tissue of the ribs and 
sternum. The marrow is abundantly infiltrated with lymphoid cells, 
and the vascular network with its delicate connective tissue, which 
exists in the normal condition, disappears, and only the larger arterial 
branches remain. The result is that the marrow, instead of its rose- 
color, becomes yellowish or greenish yellow.* In somewhat more 
than one half of the cases the liver is enlarged and changed in struc- 
ture by reason of the development of the new lymphadenoid tissue of 
the organ. It increases in size, sometimes immensely so, and weighs 
from four to eighteen pounds. This change is at first a mere prolifera- 
tion of the lymph-cells ; then occurs an infiltration of lymph new for- 
mations, or these are collected in masses or nodules, like tubercle. The 
cells penetrate the lobules from without inward, and by their numbers 
dispossess the hepatic cells, which atrophy and disappear, only spots 
of pigment remaining. f The most important change is that which 
gives the name to the disease, the increase of white cells in the blood. 

* Mosler, op. cit. 

I Rindfleisch, "Pathological Histology," pp. 183, 473, American edition. 



LEUCOCYTIIEMIA. 



231 



The gross amount of blood is not lessened, but its specific gravity is 
reduced from 1055 to 1040, even to 1035.* The color is jDaler than 
normal, and purulent looking. The proportion of white corpuscles is 
relatively greatly increased ; but the numbers vary from one to ten, 
to one to two ; indeed, the white and the red may be equal in num- 
bers ; the white may even preponderate. The white corpuscles may 
differ from the normal in being larger ; in splenic leucocythemia they 
contain one or several nuclei ; sometimes the cells are smaller, and 
there is one large nucleus ; and occasionally transitional forms are dis- 
covered between the white and red, such as are found in the cell- 
masses of the marrow.f The red corpuscles are both relatively and 
absolutely diminished in numbers, the water and fibrin are increased, 
the iron diminished, and certain abnormal ingredients are present, as 
formic, lactic, and acetic acids, hypoxanthin, uric acid, leucin, tyrosin ; 
but, of these, lactic and formic acids and hypoxanthin only are con- 
stantly present (Mosler). According to the same authority, the reac- 
tion of the blood in this disease is not acid, but alkaline. The morbid 
processes of leucocythemia are not those of a merely splenic disease — 
a local malady. Hyperplasia of the spleen is, however, the first link 
in the chain ; from this organ, immense numbers of leucocytes pour 
into the blood, and also, it is probable, some products of the splenic 
pulp, as lactic and formic acid, and hypoxanthin, etc. ; the next step 
consists in the transplantation and subsequent development of hetero- 
plastic materials in other organs, as the liver, etc. 

Symptoms. — According to the preponderance of the leucsemic pro- 
cess in the spleen, lymphatics, or marrow of bones, the disease is en- 
titled splenic leucocythemia, lymphatic leucocythemia, and myelogenic 
leucocythemia — for these organs seem equally to possess the power of 
producing white corpuscles and introducing them into the blood, and 
one may perform the office for the others. When the spleen is re- 
moved there are very few defined disturbances of the functions, as the 
lymphatics and the marrow of bone perform the necessary offices. It 
is the splenic form of the disease which is usually encountered, or the 
splenic-lymphatic, and the lymphatic very rarely, and the myelogenic 
never. The development of leucocythemia is so gradual that the be- 
ginning of symptoms usually passes unnoticed, unless preceded by 
syphilitic or other lesions, to which attention has been directed. There 
is usually a history of the gradual appearance of weakness and aniemia, 
inability for mental and especially for any physical exertion, headache, 
ringing in the ears, vertigo, palpitation. There are, as the angemia 
gradually develops, alternations of an improved state with more de- 
cided decline, but the constant tendency is downward. These pro- 

* Wagner, op. cit, p. 546. 

f Renaut, " Archives de Physiologic," September, 1881. 



232 



DISEASES OF THE BLOOD-FORMING ORGANS. 



dromal symptoms last from a few months to several years, the average 
being about eighteen months. As the cases progress, the condition of 
anaemia becomes more profound ; the lymphatics of the neck, or groin, 
or other superficial parts, are found to be somewhat enlarged, and now 
careful palpation discloses enlargement of the spleen. There are, then, 
extreme pallor, weakness and exhaustion, and breathlessness on the 
slightest exertion. The headache, vertigo, and tinnitus continue, and 
the mental state is depressed, hypochondriacal, and irritable, " due to 
the accumulation of white corpuscles in the capillary vessels of the 
brain."* The vision is obscure and amblyopic. There are now and 
then, without apparent cause, attacks of profuse sweating, and scaly 
and pustular eruptions. There is usually some feverishness toward 
evening, and the pulse is always accelerated. Q5dema of the ankles, 
puffiness of the eyelids, and some effusion in the cavities are results of 
the hydrsemia. The changed condition of the blood also induces the 
hsemorrhagic cachexia or diathesis, and bleeding occurs from the nose, 
mouth, and other mucous surfaces, and from slight woundSj so that 
the least abrasion or cut gives rise to severe haemorrhage. The ves- 
sels remain unaffected except by capillary thromboses, due to the aggre- 
gation and adhesion of white cells, and such changes in their walls as 
are produced by imperfect nutrition. A soft-blowing murmur — ana3mic 
murmur — is audible at the base of the heart. The appearance of the 
blood is very characteristic. A ready method of demonstrating its char- 
acter has been mentioned by Sir William W. Gull f — that is, " puncture 
the finger of the patient, and receive the blood on to a piece of white 
linen, or a lawn handkerchief, and put by the side of it a similar stain 
of blood from a healthy subject. The full color of the latter contrasts 
strikingly with the stain of the former, which is hardly of a blood-color, 
and translucent." The relative proportion of blood-globules is best 
ascertained by counting, employing for this purpose the haemacytometer 
as arranged by Gowers. In order to constitute leucocythemia, it has 
been attempted to fix arbitrary numbers, but, while the proportion of 
white to red corpuscles must be increased very largely above the nor- 
mal, yet no definite number can be stated, and hence the diagnosis 
must rest rather on the concurrence of the splenic and lymphatic en- 
largements with increase of the Avhite corpuscles. It may, however, 
be stated, as an approximation to the truth, that the relative proportion 
of white to red should be reduced to one to six, in order to constitute 
true leucocythemia. It has already been stated to what extent the dis- 
proportion may be carried in this disease when fully established. When 
the spleen has reached its maximum, the abdomen is greatly enlarged, 

* Ollivior et Ranvier, '* Nouvelles Observations pour servir a I'llistoire de la Leucocy- 
themie; " "Archives de Physiologic," vol. ii, 1869, p. 518. 

+ "Transactions of the Pathological Society," vol. xxix, 1878, p. 383. 



LEUCOCYTHEMIA. 



and prominent, but in ordinary cases an increase of size, and usually 
of density, can be ascertained on palpation. The mesenteric glands 
can usually be felt through the abdominal walls, enlarged and firmer. 
The inguinal, cervical, and other lymphatic glands, are also enlarged. 
A capital illustration of these is given in the plate accompanying Sur- 
geon-Major Porter's case, * as reported to the London Pathological 
Society. 

The tumors of the tongue and tonsils interfere with mastication 
and the act of swallowing ; the gums become spongy and tender. The 
appetite may be keen ; it may be normal ; it maybe wanting entirely. 
Constipation at first is present ; then diarrhoea alternates with consti- 
pation, and finally diarrhoea persists. The urine has a higher specific 
gravity than normal — from 1020 to 1030. The urea is greatly dimin- 
ished, but the uric acid is increased, and hypoxanthin is present, in the 
cases of splenic leucocythemia. 

Course, Duration, and Termination. — Leucocythemia is essentially 
a chronic malady. Its origin can not be often determined, because there 
is a slow development of uneasiness in the splenic region, fullness of 
the abdomen, breathlessness on exertion, and anaemia and pallor of the 
skin. The swelling of the spleen, until its size is considerable, escapes 
recognition ; when, however, the external lymphatic glands enlarge, 
attention is earlier directed to the nature of the case. Then an ex- 
amination of the blood furnishes conclusive evidence. When the 
hsemorrhagic diathesis comes on, bleeding may be so severe as to ex- 
haust the patient rapidly, or death may occur suddenly by cerebral 
haemorrhage. The course and duration of cases are materially affected 
by the hiemorrhagic diathesis. When this does not exist, the progress 
is much slower and the duration more prolonged. The glandular and 
splenic enlargements may become enormous, and the patient die ulti- 
mately of exhaustion, death being preceded by cerebral symptoms — 
delirium, stupor, and insensibility. The case may be terminated by 
some intercurrent malady, as pericarditis, pleuritis, pneumonia, etc. The 
symptoms of the first stage, as already stated, continue for months, 
even years, the average being about eighteen months, and the second 
stage, or fully developed malady, lasting about one year. Probably 
the average duration of the whole disease is two years. 

Diagnosis. — In the first stage of this malady a distinction is not 
possible from ordinary anoBmia and chlorosis. When, however, the 
spleen enlarges, and the lymphatic glands also, and the anaemia be- 
comes extreme, the picture of the disease is complete, and no one i30s- 
sessed of any knowledge could fail to recognize it. In the early stage, 
the persistence of the anaemia under appropriate treatment, the ex- 
treme degree of pallor, the breathlessness under slight exertion, the 

* " Transactions of the Pathological Society," vol. xxix, p. 339, op. cit. 



234 



DISEASES OF THE BLOOD-FORMING ORGANS. 



vertiginous sensations, the hemorrhagic diathesis, must awaken sus- 
picion as to the character of the malady, before the splenic disease 
manifests itself. 

Treatment. — Unfortunately, we possess no specific against this dis- 
ease, and hence the treatment must be symptomatic. Iron, which is a 
specific in anaemia, has no influence of a curative kind in leucocythe- 
mia, but it is useful as supplying a material needed in the process of 
repair. There are several remedies which affect the spleen, in a way 
which indicates a specificity of action : they are quinia, ergotin, and 
electricity. Quinia, iron, and ergotin can be given together in pill-form 
— five grains of quinia, one grain of reduced iron, and two grains of 
ergotin, should be administered three times a day. Simultaneously, 
electricity can be applied in the form of faradic electricity to the sple- 
nic region, or by means of an insulated electrode in the rectum, and 
the other over the spleen. A slowly interrupted galvanic current is, 
the author believes, more efiicient. Good results are obtained from 
the local application of the ointment of the biniodide of mercury — un- 
guentum hydrargyri iodidi rubri — to the splenic region. The oint- 
ment should be thoroughly rubbed in while the direct rays of the sun 
are falling on the part, or before a bright fire. The ointment is rubbed 
in daily, until the skin begins to vesicate, when it must be discontinued, 
but resumed again when the skin has recovered from the effects of 
previous applications. As the breathlessness on exertion, the vertigo, 
the mental troubles, the effusions, the haemorrhages, etc., are due to the 
impoverished blood, attention must be directed to the central lesion, 
rather than administer remedies for individual symptoms. In some 
cases good results have apparently followed tranfusion of blood ; but 
they were examples of the hasmorrhagic diathesis, rather than of true 
lencocythemia. In the latter disease transfusion is useless — three cases 
in which it was employed by Stoll, of Wurzburg, having proved fatal. 
As the function of blood-production is at fault, attention to the first 
steps in the process is necessary : in other words, careful alimentation 
is of great importance. Whether the appetite be languid or voracious, 
to insure thorough digestion, pepsin and muriatic acid should be ad- 
ministered after each meal. As, in the progress of the disease, the 
liver and intestinal glandular apparatus are disabled, fats, starches, and 
sugars should be excluded from the diet as far as possible, and the 
patient be fed on fresh meats, milk, eggs, and fish. Cases not yielding 
to the plan above indicated may be treated with arsenic, arseniate of 
iron, especially Fowler's solution, and the phosphates or compound 
sirup of the hypophosphites. These remedies should, of course, be 
pushed, especially the phosphates, for no immediate results can be ob- 
tained from them. Arsenic has been administered hypodermatically, 
and injected directly into the substance of the enlarged spleen with 
asserted advantage. 



ALDISOX'S DISEASE. 



235 



ADDISON'S DISEASE— MELASMA SUPRARENALE. 

Definition. — Dr. Addison, of Gay's Hospital, in London, in 1855 
announced the diseoYerv of a disease in which, with a peculiar bronze- 
like discoloration of the skin, there are associated great weakness and 
anaemia, the whole being due to disease of the supra-renal bodies. 
His name has, by common consent, been associated with this disease 
permanently, which is hence known as Addison^s Disease — Morhiis 
Addtsonii. It is sometimes called "the bronzed-skin disease," "melas- 
ma suprarenale," etc. It may be defined, in the words of Averbeck,* 
as " a well-marked constitutional disease, exhibiting itself locally as a 
chronic inflammation of the supra-renal capsules, but in its essence 
consisting in a peculiar anaemic condition, always tending toward 
death, which is characterized by intense deyelopment of pigment in 
the cells of the rete Malpighii and in the epithelium of the mucous 
membrane of the mouth." 

Causes. — Although the anatomical structure of the supra-renal bod- 
ies has been successfully studied, the knowledge of their physiologi- 
cal functions has not adyanced correspondingly. It is, therefore, dif- 
ficult, eyen impossible, to trace a relationship between symptoms of 
the disease and some obseryed lesion. It occurs rather more fre- 
quently among men, and is a disease of adult Kfe, no case occurring 
before ten or after sixty years of age. Dr. Greenhow \ has collected 
one hundred and nineteen cases in males and sixty-four in females, of 
whom eleyen years was the youngest, and fifty-nine the oldest, age at 
which death occurred. There is, howeyer, an exceptional case in 
which the limit of maximum age is exceeded — that of a woman who 
is reported to haye died at sixty-nine. Various depressing moral emo- 
tions and eyil hygienic influences haye been assigned a causal relation 
to the disease. Grief, anxiety, fear, exposure to cold and dampness, 
and want, are supposed exciting causes. A considerable proportion of 
the cases haye coexisted with tuberculosis in other organs, and a few 
well-marked examples of the disease haye been apparently due to a 
tubercular degeneration of the supra-renal bodies ; hence the strumous 
constitution or diathesis is supposed to be intimately related to the 
disease. In Ayerbeck's collection of fifty-one cases, there were eyi- 
dences of tubercular, strumous, or caseous degeneration in thirty-six. 
Greenhow holds that the condition of general tuberculosis, without 
being necessarily causatiye, frequently coexists with Addison's dis- 
ease, and that " in a certain small number of cases the genuine lesion 
in the capsule has been found coexisting with advanced phthisis or 
general tuberculosis." It seems clearly established that Addison's 
disease is frequently associated with inflammation and suppuration in 

* " Die Addison'sche Krankheit," Erlangen, 1869. (Merkel.) 
f "The Croonian Lectures for 1875," "The Lancet," toI. i, 1SY5. 



236 



DISEASES OF THE BLOOD-FORMIXG ORGANS. 



neighboring structures — extending to and ultimately involving the 
supra-renal bodies. Caries of the vertebra, psoas and perinephritic 
abscess, etc., are examples of such causes. Greenhow insists on trau- 
matism as an influential factor, but this must be regarded as an excit- 
ing cause. A considerable proportion of cases occur without any ob- 
vious reason for their appearance. 

Pathological Anatomy. — The condition of the supra-renal bodies 
varies with the period of the disease at which the examination is 
made. Virchow* describes a cheesy degeneration, beginning in the 
medullary tissue as small gra)^ nodules, which gradually increase in 
size, amalgamate, and ultimately become caseous. A portion of the 
body may remain normal, or, gray nodules forming also in the corti- 
cal tissue, the whole organ may finally degenerate into a firm, caseous 
mass. The English authorities, especially Wilks and Greenhow, main- 
tain that the disease in the supra-renal bodies is a low form of inflam- 
mation, during the course of which these organs become infiltrated 
with a fibrous exudation that undergoes conversion into a purulent, 
caseous, or cretaceous material. According to Merkel, the process is 
essentially tubercular. The nerves having intimate relations with the 
supra-renal bodies are also affected by a low grade of inflammation, 
consisting in congestion of the neurilemma, hyperplasia of the con- 
nective tissue, atrophy, fatty degeneration, and pigmentation of the 
ganglion-cells. The capsules which are in close proximity to the solar 
plexus and semi-lunar ganglia are more abundantly supplied with 
nerves, relatively to their size, than any organs in the body. The 
cells of the medulla present a strong resemblance to the multipolar 
ganglion-cells of the brain and spinal cord, and a number of nerve- 
trunks pass through the cortical portion into the medulla (Leydig). 
From this anatomical disposition it is maintained that the medulla is 
a portion of the ganglionic nervous system, while the cortex is a vas- 
cular gland (Kolliker). The nerve-trunks are invaded by contiguity 
by the inflammation attacking the capsules. The fibers and ganglia 
of the solar plexus are also changed. The neuritis, beginning in the 
nerves of the supra-renal bodies, extends to the fibers of the plexus 
and to the semilunar ganglia, the cells of which become cloudy and 
granular and pigmented, with subsequent atrophy. Traces of old and 
recent haemorrhages are also found. 

The blood is by some said to be deficient in fibrin and to have an 
excess of white globules, and the red globules do not manifest any 
tendency to form rouleaux. Greenhow finds that the blood does not 
exhibit any appreciable alteration in typical cases, and that the changes 
observed by Buhl and others were due to coincident but accidental 
lesions in the lymphatic glands. Atrophy and fatty degeneration of 
the heart and of the intima of the vessels have been observed in some 
* " Krankhaften Gescbwiilste," Band ii, p. 689. 



ADDISON'S DISEASE. 



237 



cases. The urine is deficient in urea and in pigment, and contains an 
excess of indican. The most striking change during life — the abnor- 
mal pigmentation — is due to the deposition of granular pigment in the 
cells of the rete Malpighii, in the papillary portion of the cutis, and 
even in the connective-tissue corpuscles. Ko change occurs in the 
proper structure of the skin. Similar pigment deposits occur in the 
mucous membrane of the mouth, especially along the edges of the 
teeth, while the conjunctiva, the nails, and the skin of the palms and 
soles of the feet are entirely free from deposits. It is obvious that 
the phenomena of Addison's disease — the anaemia, the feebleness, and 
the bronzing of the skin — are due to changes in the supra-renal bodies 
or in the connected nerves or ganglia. That alteration of the capsules 
Tvill produce such symptoms can not be admitted, in view of the fact 
that cancer and other forms of degeneration have destroyed these 
bodies without causing this malady. It is the peculiar lesion of the 
supra-renal capsules, of the connected nerves, and of the solar plexus, 
with the semilunar ganglion only, that really produces the morbid com- 
plexus of Addison's disease. Unquestionably the changes in the nerves 
and ganglia are the most important pathological factors, and to them 
are ascribed the strange constitutional symptoms, including the pig- 
mentation, by the chief authorities who have discussed the pathology 
of this malady. The view that the abnormal pigmentation occurs 
through the medium of the nervous system is supported by the fact 
that the discoloration lessens with improvement in the constitutional 
state, and deepens and extends when the symptoms indicate a more 
active condition. Analogous influence of the nervous system is seen 
in those cases in which a permanent darkening of the skin has followed 
sudden fear and agony of mind (Greenhow). It is the trophic system, 
especially, which is concerned. Doubtless Jaccoud nearly expresses 
the correct pathology when he holds that in Addison's disease the 
changes in the supra-renal bodies excite an irritation of the vaso- 
motor (trophic ?) system, which requires a much longer time to pro- 
duce the pigmentation than to develop the asthenia ; hence the long 
existence of the latter before the appearance of the former. 

Symptoms. — Addison's disease develops very gradually — so gradu- 
ally that the time of beginning escapes observation. First, an un- 
wonted sense of weariness on exertion is experienced. The debility 
slowly, in some exceptional cases quickly, increases, until a marked 
degree of asthenia is reached. There is not a corresponding degree 
of anaemia and wasting, and, although the sclerotic is pearly, the mu- 
cous membrane is red, and the blood has the normal proportion of red 
globules, while the subcutaneous fat is little if at all diminished, the 
muscles being weak and flabby. Disorders of digestion succeed to the 
early symptoms of debility. An unpleasant distention of the stomach 
is felt after eating ; eructations, nausea, and occasionally vomiting oc- 



238 



DISEASES OF THE BLOOD-FORMING ORGANS. 



cur ; and during, sometimes between, the acts of digestion, considerable 
pain is felt in the stomach. Pains of a dragging, tearing character 
also occur in the hypochondria and in the spine, extending into the 
sacrum. Much tenderness is elicited by pressure in the hypochondria, 
especially in the right, where, besides, the pain is most acute. The 
joints also become the seat of considerable pain, which is increased by 
movement, but they are neither swollen nor tender. These pains are 
pretty constant, while the disorders of digestion are at first intermit- 
tent, becoming more and more frequent as the case progresses. 

With the development of these symptoms the asthenia increases. 
The least exertion induces an overpowering sense of fatigue. An 
extreme pallor of the skin — -of those parts unaffected by pigment de- 
posits — and a weak, soft, extremely small pulse, indicate the failing 
circulation. The impulse of the heart grows weaker and weaker, and 
a soft blowing murmur is audible at the base and over the course of 
the great vessels. So exceedingly weak does the heart become, that 
the patient, when still able to sit up, may have no pulse at the wrist. 
The skin is cool and the temperature is below normal, although, under 
exceptional circumstances, an evening rise to febrile heat may be ob- 
served. Meanwhile, the gastro-intestinal disturbance increases ; the 
nausea becomes constant, vomiting occurs, and diarrhoea is added to 
the other causes of depression. Under these circumstances it may 
happen that death ensues before the occurrence of the characteristic 
pigmentation. No case, however, can be regarded as strictly typical 
in which the peculiar bronzing of the skin is entirely wanting. Those 
parts of the body exposed to the light first exhibit the change in color. 
The skin, in patches and streaks, and especially about old cicatrices, 
begins to grow dusky, or grayish brown ; then assumes an olive- green 
tint, and becomes, finally, bronze or copper-colored. As the tint 
deepens, it also widens, until the whole surface is dark — mulatto-like — 
those parts naturally pigmented staining most deeply, while the palms 
and soles, the nails, and the sclerotic remain white. The mucous mem- 
brane of the mouth, also, exhibits patches of pigmentation about the 
lips and cheeks, but especially along the margin of the teeth. Noth- 
ing could be more striking than such a change in the color of the in- 
tegument, but not all cases present it in full, and an early termination 
may prevent anything like a general deposit of pigment. There may 
be in such cases only patches of pigment here and there, in situations 
where the coloring matter normally abounds, at the site of old cica- 
trices, and at points of pressure of clothing. Although cases undoubt- 
edly exist in which all the symptoms of Addison's disease are pres- 
ent, save the pigmentation, they should not be regarded as examples 
of this affection, unless an early termination prevents the full devel- 
opment. It has been suggested that cases of this disease have indeed 
proved fatal before the peculiar pigmentation could develop, by a 



ADDISON'S DISEASE. 



239 



persistent and uncontrollable vomiting, coupled with the usual asthe- 
nia. Sometimes diarrhoea has been associated with the gastric derange- 
ment, and the progress of the case accelerated by the gastro-enteritis, to 
which the fatal result was attributed. The simultaneous occurrence of 
so much pain and soreness in the epigastrium, of vomiting, and of extreme 
weakness, seems so much like the history of abdominal cancer, that a 
fatal result occurring before the pigmentation is attributed to cancer. 

Course, Duration, and Termination. — The typical examples of Ad- 
dison's disease are characterized by slowness of evolution. There are, 
however, cases much more acute in type, but these are decidedly in 
the minority. In these acute cases, after a period of unaccountable 
decline in health and activity, the patient goes to bed intensely pros- 
trated, can hardly raise himself up, and on any muscular movements 
the members tremble. Nausea, vomiting, meteoric distention of the 
abdomen, and diarrhoea supervene, rapidly reducing the flesh and 
strength. The pulse grows quick and small, and the action of the 
heart, though rapid, is excessively weak. In these cases, usually, 
there is considerable febrile disturbance, quite in contrast to the sub- 
normal temperature of the chronic type. 

For many months in the ordinary cases the progress is very slow ; 
apparently, indeed, unchanged. Meanwhile the asthenia increases, 
the gastric disturbance grows worse, frequent vomiting occurs, and a 
severe, sometimes uncontrollable, watery diarrhoea sets in. Fainting 
on attempting to rise, severe tinnitus aurium, headache, failure of 
memory, great mental feebleness, muscular twitching, epileptoid seiz- 
ures, are in turn experienced as the case progresses toward the end. 
Various abnormal nervous manifestations occur, and in one case 
(Broadbent's) choreic attacks came on. Meanwhile, the abnormal pig- 
mentation increases until the whole body becomes intensely bronzed. 
The only termination is by death. In a large proportion the immedi- 
ate cause of death is phthisis — tuberculosis frequently coexisting with 
the disease, if, indeed, Addison's disease is anything else than tuber- 
culosis of the supra-renal bodies. The average duration of the cases 
is one and a half year. The most acute cases last about six months, 
while the most chronic extend over several years (Wilks). The dura- 
tion is affected chiefly by the progress made in the general tubercu- 
losis, or in the phthisis, associated with the majority of cases. Ross- 
bach treats of the association of Addison's disease with scleroderma.* 
In many instances caries of the vertebra, psoas abscess, and inflamma- 
tion and suppuration in the neighborhood of the capsules have existed. f 
The progress and termination may therefore be affected by these asso- 
ciated lesions. Those cases in which the usual coexistent diseases are 
wanting, and the anatomical changes are restricted to the supra-renal 
capsules, terminate by asthenia, and are the most protracted. 

* Virchow's " Archiv," Band li, p. 100, f Greenhow, supra. 



240 



DISEASES OF THE BLOOD-FORMING ORGANS. 



Diagnosis. — Until the characteristic discoloration of tlie skin ap- 
pears, the diagnosis must be largely conjectural. A persistent and 
unaccountable asthenia, coinciding with an increase in the depth of 
color of the natural pigment, and the appearance of grayish-brown 
spots, ought to be rightly interpreted. Brownish spots appear on the 
face and other parts in some women during pregnancy and at each 
menstrual period, but in these cases the peculiar asthenia is absent. 
Greenhow describes * a case of " Vagabond's discoloration," which 
simulated Addison's disease ; but the diagnosis was rendered easy by 
the free application of soap-and- water. Abnormal pigmentation occurs 
in some cases of exophthalmic goitre, but, while in this disease there is 
a marked degree of asthenia, the other symptoms of the morbid com- 
plexus readily determine its character. Angemia should not be con- 
founded with asthenia. The anaemia of chronic malarial poisoning, 
accompanied by more or less fawn-color of the skin, may be mistaken 
for the asthenia of Addison's disease. The distinction ought to be 
made between anaemia and asthenia, which will be confirmed by the 
previous history in both diseases. The discoloration of the skin when 
general may be confounded with jaundice, but the distinction is made 
by the extreme weakness which accompanies Addison's disease, and 
by the fact that in jaundice the change of color extends to the eye, to 
the mucous membrane, and to pathological fluids as well as to normal 
excretions, as the urine. Pityriasis versicolor is readily distinguished 
by the roughness of the skin, by the occurrence of the discoloration in 
patches, and by the presence of a parasitic organism. Furthermore, 
pityriasis versicolor does not materially affect the general health, and 
is not accompanied by the profound depression characteristic of Addi- 
son's disease. Leucoderma is readily diagnosticated by the accompa- 
nying patches of pigmentation and abnormal whiteness of the skin. 

Treatment. — The treatment, although unpromising, is not without 
utility. There are two objects to be attained by remedies : to improve 
the cachexia ; to relieve the more active symptoms. In the first group 
are such remedies as the sirup of the iodides of iron and manganese, 
cod-liver oil, chloride of calcium, quinia, iron, etc. Phosphorus has 
been given with obvious good results in several instances, and the 
phosphates and phosphites are excellent reconstituent tonics, which 
may be useful in this disease. Arsenic, also, is a promising remedy. 
Probably the best effects will be obtained from the administration of 
phosphorus in cod-liver oil, and the chloride of calcium with the sirup 
of the iodides. 

For the nausea and vomiting, minute doses of Fowler's solution, 
bismuth and carbolic acid, and hydrocyanic acid, may be in turn tried. 
Tincture of nux vomica is an excellent stomachic tonic under these 
circumstances. 

* " The Clinical Society's Transactions," vol. ix, p. 44. 



MELAN^MIA. 



241 



MELAN^MIA. 

Pathogeny. — The term melanoemia is applied to a condition of the 
blood in which are found small brownish or black masses, scarcely so 
large as a red-blood globule, of pigment matter. Sometimes these par- 
ticles are oval, or round in shape, sometimes irregular, and rarely 
stratified by the presence of a colorless capsule (Rindfleisch). Occa- 
sionally true pigment-cells are observed. This pigment is found every- 
where in the blood, but exists in greatest quantity in the spleen, which 
becomes, according to the quantity, a chocolate, brownish, or blackish 
color. The spleen may, indeed, be almost the sole place of deposit, 
but the liver is next in respect to place and quantity, and after the 
liver are the lungs, brain, and kidneys. Opinions differ as to the origin 
of the pigment, but the weight of authority is in favor of the splenic 
origin, and that it is a product of the disintegration of the red-blood 
corpuscles. As during malarial fever this destruction of the red cor- 
puscles is more rapid than in any other form of acute infectious dis- 
ease, melangemia is a product of malarial diseases. The pathological 
changes characteristic of this state are found in the spleen, liver, lym- 
phatic glands, marrow of bones, etc. The spleen is enlarged, its con- 
sistence soft, if there have been recent attacks, and firmer if consider- 
able time has elapsed. The color depends on the quantity of pigment, 
and is dark slate, or brown, or black. The deposits of pigment take 
place chiefly along the veins, which are bordered by a dark line, and 
to a less extent along the arteries, and the whole splenic pulp may be 
tinted by it. The lymphatics and the marrow, also, contain pigment, 
which, with lymphoid cells, is found in the vicinity of the vessels. 
Characteristic changes, due to pigment deposition, also occur in the 
liver. As elsewhere, the pigment deposits are found alongside the 
vessels. According to Rindfleisch,^ small extravasations of blood in 
Glisson's capsule, and in the parenchyma of the liver, initiate the pig- 
ment formation. The pigment granules accumulate about the branches 
of the portal vein and hepatic artery, about the intralobular and he- 
patic veins, but the hepatic cells are not involved. The whole organ 
has a steel-gray or blackish tint. Ultimately the nutrition of the 
organ may be so impaired that atrophy results. 

As the pigment granules may be larger in caliber than the blood 
corpuscles, they will necessarily be arrested in those organs having a 
fine capillary network. Pigment embolisms of the cerebral vessels 
are, consequently, results of this process. Pigment blocking of the 
cerebral capillaries has precisely the same effects that other emboli 
produce : collateral hyperaemia, extravasations, and oedema, with the 
important structural alterations following in their wake. 

* "Pathological Ilistolosy," American edition, p. IST. 

18 



242 



DISEASES OF THE BLOOD-FORMING ORGANS. 



Symptoms. — Melansemia is an accident or complication of the se- 
verer cases of malarial fever. The changes in the spleen and liver do 
not cause symptoms, except the enlargement of the former organ, to 
be made out by palpation and percussion. The cerebral symptoms 
are, however, very pronounced. There are present, when the pigment 
embolisms occur, more or less intense headache, vertigo, delirium either 
low-muttering, or active and furious, passing into stupor, coma, and 
insensibility. There are occasionally paralysis and epileptiform at- 
tacks, but usually the motor disturbances are not more than twitchings 
of the muscles, ptosis and weakness of the muscles of the extremities. 
In cases seen by the author the delirium was wdld — delirium ferox — 
and the motor troubles were those of paresis of muscular groups. In 
the author's cases also there was a very high temperature, to which the 
cerebral disturbance may have been in part due. In the more chronic 
cases, without fever, there are persistent headache and vertigo, the 
strength is easily exhausted, the nutrition inactive, and the surface, 
especially of those parts of the body exposed to the light, has a bronzed 
appearance. In such, we may assume that the pigmentation of the 
brain is confined to deposits alongside the vessels, and does not in- 
clude embolic obstruction of the capillaries by pigment masses. When 
the last-mentioned condition exists, there will be more decided mental 
symptoms, epileptiform attacks, paralysis, etc. In the milder form, 
recovery may ultimately ensue if the patient be removed from mias- 
matic influences. In those cases of capillary embolisms, it is doubt- 
ful if recovery ever can take place. Nevertheless, treatment must be 
pursued from the symptomatic standpoint, for it may be that success 
will eventually be the reward of persistent efforts. 

Treatment. — There are two therapeutical indications : to check the 
waste of red-blood globules ; to effect the solution and extrusion of 
pigment. Quinine, iron, ergotin, and digitalis — which may be com- 
bined — are the most efiicient remedies for the first indication ; pyro- 
phosphate of sodium for the second. If the symptoms are acute, 
quinia must be given in large doses — twenty to forty grains a day — if 
less so, five, even three grains three times a day. The other remedies 
should be prescribed accordingly.* The utility of the phosphate of 
sodium consists in its power to maintain the alkalinity of the blood, in 
its effects on the hepatic secretion, and in its influence over the meta- 
morphosis of tissue. 

HEMOPHILIA. 

Definition. — The term hcemophilia is applied to a congenital state 
characterized by the habitual occurrence of hiemorrhages. As the 

* I^. Quiniae sulph. 3 j, ferri redact! gr. x, ergotia 3j, digitalis gr. x. Make into 
ten wafers. One wafer three times a day. . Sodii pyrophosphat. ^ j, ferri pyrophos- 
phat. 3j. M. Take a teaspoonful in sufficient water three times a day before meals. 



HEMOPHILIA. 



243 



disposition to bleeding is inherited, and is transmitted in families, 
persons so affected are called " bleeders." 

Causes. — Heredity is the most important factor in its causation. 
It is an unfortunate fact that families of bleeders are remarkable for 
fertility. The males are affected thirteen times more frequently than 
females (Immermann *), but, on the other hand, women transmit the 
disease more certainly than males — for example, a male bleeder mar- 
rying a healthy woman, without taint of haemophilia, has children 
usually free from this hereditary disposition ; but a female bleeder 
marrying a healthy male has quite uniformly bleeder children. Again, 
if a woman, member of a bleeder family, but herself not a bleeder, 
marry, she will have some children who inherit the family taint. The 
disposition to bleeding usually manifests itself about the first denti- 
tion, and in a large proportion within the first year. The hsemor- 
rhagic diathesis existing, a slight injury will suffice to start the bleed- 
ing : thus, lancing the gums, leech-bites, the Jewish rite of circum- 
cision, slight cuts or abrasion of the skin, have been followed by un- 
controllable haemorrhage. The bleeding having once occurred, the 
tendency to attacks is thereby greatly increased. 

Symptoms.— There does not seem to be anything peculiar in. the 
bleeders as respects bodily conformation, temperament, habits, and 
disposition, except the hiemorrhagic diathesis, although it is said 
that they are usually persons of superior mental endowments 
(Leggt). 

There are two distinct forms of hcemorrhage : the external^ in which 
the blood pours out on the surface of the wound or abrasion ; the inter- 
stitial^ in which the blood diffuses into the interstices of the adjacent 
tissues. Frequently, if not usually, both forms occur at the same time. 
The external form may be the result of injury, and is therefore trau- 
matic^ or it occurs spontaneously^ and is named accordingly. The ex- 
ternal and traumatic form is single, for it is comparatively rare for 
more than one point of injury to exist at a time. On the other hand, 
the spontaneous haemorrhage, indicating a more active state of the vice, 
may occur simultaneously at several points. The most usual site of 
the spontaneous haemorrhage is the mucous membrane, especially of 
the oral and nasal cavity ; of the stomach and intestines ; of the bron- 
chi ; of the genito-urinary passages — named in the relative order of fre- 
quency. Recent cicatrices, that are still vascular, ulcers of the skin, and 
irritated surfaces, invite the haemorrhage. Again, in the most perfect 
specimens of haemophilia, bleeding occurs without any change in the 
skin to start it, and takes place from the fingers, toes, lobes of the ears, 
back of the hand, etc. By far the most common form of bleeding is 

* Ziemssen's ** Cyclopaedia," vol. xvii, article " Haemophilia." 

f Dr. J. Wickhara Legg, '* Treatise on Haemophilia," London, 1S72, H. K. Lewis, 
p. 158. 



244 



DISEASES OF THE BLOOD-FORMING ORGANS. 



epistaxis, which occurs, according to the statistics of Grandidier,* four 
times more often than hemorrhage from the gums, which comes next 
in frequency, then intestinal haemorrhage, haemoptysis, ha^maturia, 
hsematemesis, etc., as named. 

The blood escapes from the smallest capillaries, under very strong 
pressure, and persists obstinately, in spite of the most powerful means 
to arrest it, hours, days, and weeks together. The result is an extreme 
degree of anaemia — the skin pallid, the face drawn, lips retracted, the 
mucous membrane white and sticky, the pulse small, weak, or not to 
be felt at the wrist ; a soft, systolic murmur at the base, and a venous 
hum over the great veins ; or the action of the heart may be too feeble 
to be recognized. Consciousness may be lost, and death occur in syn- 
cope. Owing to the extreme cerebral anaemia, there may be illusions, 
hallucinations, or attacks of convulsions, as in animals bled to death 
(Kussmaul and Tenner f). In the syncope, a hemorrhage which could 
not be arrested may cease spontaneously. Notwithstangling the enor- 
mous losses of blood, its reproduction takes place quickly, and between 
the seizures the bleeders may present the rosy hue of health. The 
amount sometimes lost seems almost incredible — in one case (Coates) 
reaching the enormous loss of three gallons in eleven days. The state 
of the blood in bleeders varies with the conditions of health and after 
loss by haemorrhage — that is, becomes more watery with loss — but other- 
wise there is no difference in composition as compared with healthy 
blood, except that the former contains somewhat more red globules 
and more fibrin than the latter, or is richer than ordinary normal 
blood. The interstitial bleedings occur chiefly in the skin and subcu- 
taneous connective tissue, and when traumatic are observed in parts 
subject to injury, as the back, buttocks, trochanters, while the spon- 
taneous are observed mostly on the scalp, the scrotum, and the legs. 
Very small extravasations are csilled 2yetechice ; larger ones, ecchymoses. 
The blood undergoes the usual changes of extravasated blood : at first 
a bluish red, then brownish, with green borders, then yellowish — sev- 
eral weeks being occupied in these transformations. Sometimes con- 
siderable accumulations of blood are formed, constituting blood-tumors, 
and are found about the false ribs, on the back, on the inner face of the 
thighs, in the popliteal space, and on the lower extremities. They vary 
in size from a hickory-nut to a goose-egg, and attain even larger pro- 
portions, and also vary in firmness according to their position. They 
are of a bluish-black color, and are surrounded by a rose-colored zone, 
tender to the touch, and signifying the formation of a limiting mem- 
brane. These tumors may undergo the usual preparatory changes and 
be slowly absorbed, or suppuration may occur, and discharge of pus and 

* Schmidt's " Jahrbiicher," vol. cxvii, p. 329, " Bericht iiber die neucrn Beobachtuiv 
gen und Leistungen ein Gebicte der Htemophilie seit, 1854." 
f Sydenham Society edition. 



HEMOPHILIA. 



245 



shreds of tissue take place, with considerable haemorrhage. The only- 
changes to account for the phenomena of haemophilia are abnormal 
disposition and arrangement of the superficial vessels of the body. 
The superficial vessels are abnormally large, the intima remarkably 
thin. On the other hand, the lumen of the large arteries (aorta and 
pulmonary) is found to be narrow. The intima of both classes of 
vessels is usually in a state of fatty degeneration. There has usually 
existed an hypertrophy of the left ventricle. These changes in the 
vascular system, and the condition of vascular fullness and congestion, 
which marks the healthy state of bleeders, together with the abnormal 
richness of the blood, serve in a measure to account for the extraordi- 
nary clinical history of this disease. 

Complications. — In the bleeder families neuralgic and rheumatic 
affections seem common. Toothache and myalgia are said to be fre- 
quent. Rheumatic joint and muscular affections also occur. 

Duration and Termination. — The duration of haemophilia is the life 
of the individual. If the bleeder escape the accidents of childhood, 
there may be no manifestation of the diathesis until after adult life. A 
young woman died on her marriage-night, from haemorrhage occasioned 
by rupture of the hymen. A single haemorrhage may take life in a few 
hours, as in the case just narrated, or death may result from several 
weeks of bleeding. The usual result is death. Such small operations 
as extraction of teeth, circumcision, leeching, etc., are very apt to cause 
death, while vaccination is much less dangerous. Of 152 bleeder boys, 
133 died before attaining twenty-one years of age.* The haemorrhagic 
disposition may disappear in middle life, but this has happened in nine 
cases only ; and, when it does cease, rheumatic and gouty attacks are 
experienced. 

Treatment. — All injuries must be carefully guarded against. Bleed- 
ing from any abrasion or puncture should be restrained by pressure, if 
possible. Every form of astringent vegetable and mineral has been 
used. Epistaxis, which is the most usual form of haemorrhage, is best 
arrested by plugging the nares and the application of ice, and by the 
administration of ergotin. Bleeding from the gums is more easily 
handled, in that the styptic preparations of iron, the actual cautery, 
and compression can be used. In haematuria, krameria, infusion of 
digitalis, ergotin, and gallic acid should be administered. Of the sys- 
temic remedies there can be no question as to the superiority of ergot 
and digitalis, and experience is in harmony with physiological ex- 
periment. Cures have apparently followed the use of ergot. The 
administration should never be subcutaneously, and the dose of the 
aqueous extract will range from two to five grains, as often as may 
be necessary. When attacks are impending, a brisk cathartic of Ep- 



Grandidier, op. cit., p. 833. 



246 



DISEASES OF THE BLOOD-FORMIXG ORGANS. 



som salts should be administered to lower the blood-pressure, and 
the diet should consist of fruits and vegetables only. Sulphuric acid 
in dilute solution should be taken as a drink. Full doses of digi- 
talis, the patient maintaining absolute recumbency, should then be 
administered, and when the haemorrhage comes on the exhibition of 
ergotin, etc., should be practiced. This method is the best now known 
for arresting the attacks of bleeding. 

SCORBUTUS— SCURVYo 

Definition. — Scurvy is a disease of nutrition, in which the blood is 
so far impoverished that transudations occur, and large hsemorrhagic 
ecchymoses become visible in various places. 

Causes. — This disease occurs more frequently in men, because their 
occupations expose them more to its causes, and in the feeble and 
cachectic, especially those who are debilitated by syphilis and mercu- 
rialism, and by marsh-miasm. Scurvy usually happens in bodies of 
men, as soldiers and sailors, who are under the same evil influences, 
and hence numbers are attacked nearly simultaneously — the cachectic 
falling victims before the robust. The chief factor is defective ali- 
mentation, not in respect to quantity so much as quality. The contin- 
ued use of salted meat and fish and the absence of fresh meat and fresh 
vegetables for a long period from the diet are the great cause, and all 
other influences are merely adjuncts. When such fresh vegetables as po- 
tatoes, cabbage, and onions, are supplied, although the other components 
of the ration may consist of salted and dried meats, scurvy will not oc- 
cur. So well is this fact understood now, that some one of these arti- 
cles always enters into the diet of armies and prisons, and, if not attain- 
able in a perfectly fresh state, are supplied in the form of " desiccated 
vegetables," sauerkraut, etc. Garrod, and afterward Hammond, at- 
tempted to show that the constituent, the absence of which is the cause 
of scurvy, is potash ; and that those vegetables most effective in pre- 
venting and curing scurvy are remarkable for the quantity of potash 
which they contain, and of these the potato stands at the head. Un- 
doubtedly, bad hygienic influences exert an influence in the produc- 
tion of scurvy. Living in houses that are dark, damp, and confined, 
want of exercise, depression of spirits (defeat), eiinui, all have more 
or less effect in depressing the bodily functions, and thus favor the ill 
effects of an improper diet. 

Pathological Anatomy.— Cadaveric rigidity is slight ; suggillations 
are extensive on the dependent parts ; petechias and ecchymoses are 
found on the body and the extremities ; the skin is muddy, inelastic, 
and scaly. The petechial spots are formed by an extravasation pro- 
ceeding from the capillary network about the hair-follicles, while the 
larger ecchymoses come from the vessels of the derma. The indura- 



SCORBUTUS. 



247 



tions of the connective tissue, subcutaneous and deeper, are due to 
infiltration by coagulated blood. The subsequent changes in the 
clots are the explanation of the appearance presented by these indura- 
tions, and depend on the greater or less amount of red globules, and 
on the solution of the fibrin, or its organization. The fibrin may be- 
come organized to that extent in which muscular atrophy and con- 
tractions resulting in deformities must ensue. In a similar manner, 
an extravasation into the substance of a muscle may lead to atrophy, 
the muscular elements being supplanted by indurated connective tis- 
sue. These atrophic alterations and deformities are results of long- 
standing changes. Recent extravasations, in scorbutus, under appror 
priate management, undergo the same regressive changes as a blood- 
clot in the normal state, though somewhat slower, and nothing is 
ioimdjyost mortem after the process is completed. The mucous mem- 
brane of the mouth is the seat of extensive hDsmorrhagic infiltration, 
and is therefore swollen and spongy ; but in old cases the gums may be 
thickened and indurated, due to the formation of new connective tis- 
sue. There is more or less effusion into the serous cavities of a straw- 
colored or sanguinolent serum ; the membranes are injected, or coated 
with exudations, or stained by spots of hcemorrhagic extravasation. 
The heart is flabby, soft, pale, and haemorrhages are found in its mus- 
cular substance. The lungs are somewhat oedematous, the posterior 
and dependent parts the seat of hypostatic alterations, and catarrhal 
and croupous inflammation products are found at the base and else- 
where. There may be extensive solidification from croupous pneumo- 
nia, or hsemorrhagic infarctions. There are numerous ecchymoses in 
the bronchi. The peritoneum is altered in the same manner as the 
pleura — the evidences of inflammation existing on the visceral and 
parietal layers in the form of exudations and extravasations. The 
intestinal mucous membrane is altered by hsemorrhagic spots and ero- 
sions, and sometimes by extensive losses of substance. The liver is 
not usually affected. The spleen, although often unchanged, is some- 
times enlarged and softer than normal, and occasionally there are 
found hsemorrhagic infarctions. The kidneys may be healthy, but 
the mucous membrane of the pelves, ureters, and bladder contains ero- 
sions and ecchymoses. Important alterations occur in the blood — the 
number of red globules diminished ; the white relatively increased ; 
the iron, potassa, and albumen lessened. 

Symptoms. — The onset of scurvy is so gradual that the patients do 
not know when it began. They become a little paler, and fatigue 
more readily, but after a time there is an appearance of anaemia, and 
such a degree of weakness that the least effort gives rise to exhaustion, 
and to a sense of prseccrdial oppression and weakness and palpitation 
of the heart. The increasing weakness is accompanied by a sense of 
soreness and fatigue in the muscles, like that induced by prolonged 



248 



DISEASES OF TEE BLOOD-FORMING ORGANS. 



hard work, but rest in bed relieves, as exercise increases, these sensa- 
tions. These muscular pains are especially felt in the back and the 
calves of the legs, and have a rheumatic character, and are often sup- 
posed to be rheumatic. The scorbutic subjects become exceedingly 
sensitive to cold, and continually seek the fire or put on additional 
clothing. They are somnolent, apathetic, and indisposed to any effort, 
mental or physical ; are dejected in mind, and wear an exi^ression of 
sadness. The facies presents an unearthly aspect ; the eyes are sunken 
and surrounded by livid aureola ; the lips are thin, retracted, cya- 
nosed ; the skin sallow, pallid, dry, scaly, and earthy, and here and 
there may be found indistinct spots of bronze discoloration. The sub- 
cutaneous fat has diminished, the muscles are soft and small, and the 
body-weight is reduced. Such are the symptoms of the initial or 
prodromal stage. They indicate anaemia, and are suggestive of scor- 
butus only because of the surroundings, and the presence of other 
cases. The duration of this period is from a week to two or three 
months. This prodromal stage may be wanting, but in the cases ob- 
served by the author * was always present. 

The scorbutic stage first manifests itself in the gums, which become 
of a dark-bluish color on their margins, especially at the incisor teeth, 
and are swollen, projecting between the teeth, and bleeding with a 
touch. The gums are also quite painful, so that mastication and the 
mere contact of sapid substances are distressing ; but those portions 
of the gums without teeth are free from these troubles, and hence the 
toothless, at the extremes of life, are exempt from scorbutus of the 
mouth. Again, it sometimes happens that these changes in the gums 
are entirely absent, and the first manifestation of trouble consists in 
suggillations and subcutaneous extravasations of blood and intestinal 
haemorrhage. On the other hand, there are many instances in every 
collection of cases, in which the only manifestation has been in the 
mouth, coupled with anaemia and muscular feebleness. In the severer 
cases after the prodromal stage, the weakness increases to such an 
extent that they become unable to retain the upright posture, and will 
fall into syncope in the attempt to assume this position. The action 
of the heart becomes very feeble, and any exertion brings on severe 
palpitation, with a sense of extreme praecordial oppression. Fever 
now comes on, in many cases not as a necessary element in the disease, 
but a symptomatic expression of a local inflammation of a serous mem- 
brane or other inflammatory trouble. The characteristic hridt of anae- 
mia is audible at the base of the heart and along the great vessels. 

In the further progress of the case the gums become much swollen, 

* The author saw some cases of scurvy when serving in the regular army as medical 
officer in 1857, during the winter spent in Utah, the command being on half rations, with- 
out any fresh vegetables. The description above is, in the main, based on these observa- 
tions. 



SCORBUTUS. 



249 



rise up to a level with the teeth, are horribly painful, and undergo 
ultimately an " ichorous disintegration," or diphtheritic sloughs form ; 
in either case, fetid, decomposing sloughs are cast off, leaving the 
teeth hare or loose. Serious deformities are necessarily produced by 
these losses of substance when cicatrization occurs. Extensive hiemor- 
rhagic extravasations take place in the s"kin, chiefly of the lower 
extremities and body, but rarely on the head or face. There may 
be purpuric petechise, the size of a hemp-seed, or vesicular or papu- 
lar efflorescences, or large htemorrhagic spots of irregular size, or 
vesicles of large size filled with a bloody serum. The least injury or 
contusion is followed by a suggillation. The skin, too, may become 
the seat of extensive ulcerations, gangrenous sloughs and hremorrhage. 
The subcutaneous tissue may either suddenly or gradually become 
affected by indurations often of great extent. They are at first red, 
and tender, but presently become brownish, and the epidermis peels 
off, leaving a discoloration ; or, in severer cases, an acute inflammation 
is set up, the skin gives way, and a great quantity of blood with 
shreds of tissue, often gangreneous, is discharged, leaving a more or 
less extensive foul ulcer. The muscles undergo similar changes — 
are occupied by indurations, the result of extravasation of blood into 
their substance, and either acutely inflame, there being great local 
tenderness and heat, and symptomatic fever, or the process goes on 
more slowly without fever. Haemorrhages take place from various 
mucous surfaces : epistaxis ; hsematemesis ; intestinal haemorrhage ; 
hsematuria. Fortunately, haemorrhage from the broncho-pulmonary 
mucous membrane is not common, except in cases of incipient phthis- 
is. Haemorrhages take place also on the serous surfaces, and haemor- 
rhagic effusions, the result of inflammation, are not infrequent in the 
pleura, pericardium, and peritoneum. Enlargement of the spleen, 
often to a considerable extent, occurs in a portion of the cases. Al- 
buminuria is present in the severer cases very often, and the urine is 
otherwise changed in character and composition. The most notable 
change besides the albuminuria, is the diminution, not only in the 
amount of urine secreted, but in the relative amount of its solids. 

Complications. — The periosteum, cartilages, and joints are affected 
in the worst cases. Extravasations take place under the periosteum, 
causing a painful swelling, which may take on an inflammatory char- 
acter if the extravasation be large. The epiphyses of the long bones 
become swollen, soften somewhat, and may be detached even. Haemor- 
rhagic effusions occur in the articulations, causing painful swelling, 
inflammation, and fever. Meningeal haemorrhage is a very rare acci- 
dent, but haemorrhage into the substance of the brain never occurs. 
Extravasations of blood also take place in the anterior chamber of the 
eye and under the conjunctiva. Severe inflammation may be the 
cesult. Hemeralopia, or night-blindness, has long been associated with 



250 



DISEASES OF THE BLOOD-FORMING ORGANS. 



scurvy,, but cases of scurvy are without it, and it often exists quite 
apart from scurvy. The profound alteration in the fluids and solids 
of the body caused by scorbutus invites attacks of other maladies. 
A frequent complication is croupous pneumonia, and a cause of death 
in many cases. Hsemorrhagic infarctions, usually several, sometimes 
are also found in the lungs. Ulcerative endocarditis and hsemorrhagic 
pericarditis are complications which quickly cause a fatal result. 

Diag'IlOSis. — Until the characteristic change has occurred in the 
gums, on the skin, etc., the anaemia of scorbutus is not distinguishable 
from other diseases characterized by this state. When, however, the 
gums swell, and there are petechise on the skin, and indurations be- 
neath, it is impossible to confound it with any other malady. 

Course, Duration, and Termination. — The usual course of scorbutus 
consists in the prodromal period, the fully developed attack character- 
ized by the swollen and sloughing gums, the hsemorrhagic affections 
of the skin, the extravasations into the subcutaneous areolar tissue and 
muscles, the inflammatory hsemorrhagic exudations of the serous mem- 
branes, the profound cachexia, and the period of restoration. The 
duration is usually protracted, and is influenced by the hygienic sur- 
roundings. When the disease is fully developed, the continuance of 
the causes will keep it in action and increase the morbid process, 
while recovery, even in an apparently hopeless condition, takes place 
promptly when the proper aliment is supplied. The earlier the ap- 
propriate means of cure are applied, the more perfect the restoration. 
Serious deformities may result from the inflammations of the muscles, 
bones and joints, and death quickly follows the lighting up of pleu- 
ritis, endocarditis, peritonitis, etc. These evil results only occur when 
the disease has been unusually protracted and severe. Death usually 
results from haemorrhages, from exhaustion, from a serous inflamma- 
tion, or from pneumonia, but the mortality depends almost wholly 
on the failure of the necessary supplies, and not on the virulence of 
the disease. With the progress of knowledge, scorbutus is becoming 
much less common. No longer are witnessed the frightful cases in 
armies, on shipboard, and in prisons, such as were very common only 
a century ago. 

Treatment. — The prophylaxis as well as treatment of scurvy, 
above all things, necessitates the use of anti-scorbutic food, fresh vege- 
tables of all kinds, especially the potato and sauerkraut, and lime- 
juice. In the English navy, lime-juice is most depended on ; but 
ships and bodies of troops are also supplied with "desiccated vege- 
tables," the ordinary vegetables, including cabbage, onions, potatoes, 
etc., compressed into tablets and carefully dried. Desiccated or con- 
densed milk is also utilized for the same purpose. Whenever attain- 
able, fresh meats are extremely serviceable, and, in their absence^ 
canned meats, beef -juice, and similar preparations, can be made to 



PrEPUEA. 



251 



supply tbeir place. Yeast has been found hv Neumann * to "be highly 
beneficial, and also the barm of beer. Medicines play a secondary 
part in the treatment of scurvy. In accordance with Garrod's and 
Hammond's potassa theory, we may prescribe cream-of-tartar lemon- 
ade, to be drunk freely. Quinine and sulphuric acid, either alone or 
in combination, are used to diminish transudations and to improve the 
tone of the system in general. Tincture of the chloride of iron and 
ersrot are g-iven to arrest htemorrhasce. There can be no doubt, if the 
author can depend on his own observation, of the value of whisky as 
a remedy for the scorbutic state, and to lessen or prevent the extrava- 
sations of blood. An ounce of whisky every four hours is generally 
the most useful amount. Turpentine is a highly efficient stimulant 
and haemostatic under the same conditions, and is the best dressing 
for the ulcers in the skin. Alum, tannin, subsulphate of iron, and 
chloride of iron, are the most useful local styptic applications for ar- 
resting epistaxis, and hoemorrhage from superficial wounds, or ulcers 
of the skin. Ergotin can, at the same time, be administered by the 
stomach. Red cinchona-bark in powder is an excellent dressing for 
the ulcers of the skin. As the various manifestations and localizations 
of the disease are due to the cachexia, no time should be wasted in 
treating them, but every effort put forth to improve the condition of 
the body in general. 

PURPURA— PURPURA HEMORRHAGICA— MORBUS MACULOSUS. 

Definition. — The term purpura means a bluish-red or purplish dis- 
coloration, produced by extravasation of blood ; purpura simplex is 
applied to the simplest form of this malady, in which there are only 
minute extravasations in the skin (petechia), and no haemorrhages into 
other parts ; pjurpura hct^morrhagica indicates a condition of things in 
which not only petechias appear in the skin, but ecchymoses, vibices, 
and hcemorrhages occur. Besides the variations in intensity as ex- 
pressed in the names applied to the disease, there are differences in 
character. Although a very large proportion of cases of purpura, 
whether simple or haemorrhagic, are entirely free from fever, there are 
cases of both forms in which fever is present — the febrile form (pur- 
pura febrilis). There are other cases, complicated with rheumatism, 
one or several joints being affected — rheumatic purj^ura (purpura 
rheum at ica). 

Causes and Symptoms. — Purpura is not limited by climate, race, sex, 
or social condition, but it occurs more frequently in females, and is 
more common from fifteen to twenty than at any other age. It ap- 
pears to be strictly sporadic. Convalescents from fever seem to be 



" Iminerrnarin, op. cit. 



252 



DISEASES OF THE BLOOD-FORMING ORGANS. 



specially liable to it. The disease usually begins abruptly, tbe first 
manifestation being epistaxis. In a few cases there is a prodromal 
period, of a few days, possibly a week, in which there are some languor 
and inaptitude for exertion of any kind, sometimes with feverishness, 
sometimes with rheumatic pains, and slight swelling of the joints, 
usually the ankles and knees. The next symptom is the occurrence of 
petechias on the lower extremities and body, less on the arms, and 
rarely on the face. These petechise or bluish-red spots, vary in size 
from a pin's-head to a pea, and change in color successively from blu« 
ish-red to greenish, brown, and yellow. As successive crops come 
out, the appearance of the skin is peculiar, the diiferent colors of dif- 
ferent ages being curiously intermingled. Slight injuries, blows and 
contusions, are followed by extravasations, bluish-red spots of irregu- 
lar size making their appearance. So long as the disease is limited to 
these manifestations, it is entitled purpura simplex ; but haemorrhage 
from the mucous surfaces is very common. The mucous membrane 
of the mouth is a not unusual source of haemorrhage, but the spongy 
and sloughing gums of scurvy are entirely wanting, as also the diph- 
theritic and inflammatory exudations. Haemorrhages may also occur 
in the subcutaneous areolar tissue, in the serous cavities, from the cere- 
bral meninges, but these are exceptional ; whereas the haemorrhages 
from the mucous surfaces is the special feature, and may be the only 
condition present. It has been observed a few times that the haemor- 
rhages have come on suddenly, without any other symptoms, in appar- 
ently healthy and vigorous subjects, and without impairing the general 
health ; usually, however, the repeated losses of blood cause an extreme 
degree of anaemia, manifested by pallor, emaciation, weakness and 
breathlessness on slight exertion, faintness on assuming the erect pos- 
ture, swollen ankles, etc. Before haemorrhages occur, the condition 
of the blood seems normal; but in the further progress of the. cases the 
blood becomes watery, the white corpuscles increase in number rela- 
tively, and the red corpuscles decrease, but the coagulability of the 
blood is at no period lost. Besides the presence of blood on the 
mucous surfaces and on some of the serous membranes, there are post- 
mortem changes to be noted. The haemorrhages are mere extravasa- 
tions, and under no circumstances inflammatory. The disease may 
therefore be regarded as a " transitory hcemorrhagic diathesis " (Im- 
mermann). An important result of the disease, due directly to the 
haemorrhages, but persisting after they have ceased, is anaemia. It is 
in a high degree probable that the anaemia, which is increased by the 
haemorrhage, is also a principal factor in their causation. Urticaria is 
another complication, and seems to be associated with stomach de- 
rangement. A much more rare accident is the occurrence of slough- 
ing and perforation of the intestines, produced by haemorrhagic ex* 
travasations into the tunics of the bowel. 



PURPURA. 



253 



Course, Duration, and Termination— The whole course of the dis- 
ease includes the prodromal period, the purpura simplex, the period of 
haemorrhage, and the subsequent ancemia. The duration is influenced 
materially by the number and amount of the haemorrhages. An ordi- 
nary case will last two or three weeks, but when there are repeated 
haemorrhages the disease may continue for several months. Although 
most cases recover, death sometimes happens from exhaustion, from 
internal haemorrhage, from some intercurrent malady, and from per- 
foration of the bowel. 

Diagnosis. — Purpura may be confounded with scorbutus, haemo- 
philia, progressive pernicious anaemia, leucocythemia, and cerebro- 
spinal meningitis. From scurvy it is differentiated by the absence 
of changes in the gums, of the indurations of the subcutaneous areolar 
tissue and of the muscles, of the haemorrhagic inflammation of the 
serous membranes, etc. From haemophilia the distinction is made by 
reference to the history, especially the heredity, by the period of life, 
by the bleeding from trivial wounds, so characteristic of haemophilia, 
and not of purpura. The distinction of purpura from progressive per- 
nicious anaemia rests on the fact that in the former the anaemia is pro- 
duced by the bleeding, in the latter the bleeding comes on afterward 
and is due to the poverty of blood. From leucocythemia the distinc- 
tion is made by the enlarged spleen and enlarged lymphatics, with the 
growth of which a marked degree of anaemia is coincident, and to 
which the haemorrhagic tendency succeeds. The initial symptoms of 
cerebro-spinal meningitis may be almost identical with those of pur- 
pura : purplish spots, pains in the joints, with some slight feverishness, 
but in a day or two the occurrence of nervous phenomena decides the 
question. 

Prognosis. — Most of the cases terminate in recovery. A guarded 
opinion must be expressed when the haemorrhages recur again and 
again, and when the disease occurs in broken-down subjects. 

Treatment. — The usual treatment consists in the administration of 
the mineral acids, especially the sulphuric, and of the preparations of 
iron, especially the tincture of the chloride. With these remedies 
must be conjoined a suitable dietary, fresh air, sunshine, and moderate 
exercise. If constipation be present, the most appropriate laxative is 
sulphate of magnesia with dilute sulphuric acid. If haemorrhages that 
are threatening come on with a strong pulse, flushed face, headache, 
and excitement, digitalis, quinia, and ergotin are the appropriate medi- 
caments. If there be weakness and debility, quinine and alcoholic 
stimulants moderately should be prescribed. The local means for 
arresting bleeding consist in subsulphate of iron, tannin, alcohol, ice, 
or it may be hot water, which is sometimes more effective than cold. 
For the after-anaemia iron should be pushed. 



254 



DISEASES OF THE BLOOD-FORMING ORGANS. 



AN-EMIA— OLIGiEMIA. 

Definition. — The term ayicemia^ which signifies want of blood, con- 
sists of a deficiency of its nutritive constituents. OUgcemia, which 
signifies poverty of blood, is a more correct term ; but the former is 
too firmly fixed by usage to permit a change. Although from the 
etymological point of view anaemia must be used to indicate a defi- 
ciency of blood, yet, by common usage, it is understood to mean pov- 
erty of the blood, and in that sense is employed in this work. 

Causes. — The tendency to anaemia is influenced by sex, age, and 
peculiarities of individual constitution. The female sex is more liable 
than the male, for the reason probably that the former are by nature 
less endowed with the nutritive constituents of blood. Compared to 
the body- weight, and still more decidedly by sex, the blood of women 
contains fewer red corpuscles, more water, and less albumen and salts, 
than the blood of men. While the average number of red globules 
in the blood of healthy adult males is 141*1 per 1,000 parts, in the 
healthy adult female it is 127'2 (Becquerel and Rodier*). The ex- 
tremes of life — youth and old age — are more liable to anaemia than the 
period of maturity. In early life the needs of the growing organism 
are such as to require the utmost amount of pabulum from the blood ; 
the interchanges are more rapid, the consumption of material greater, 
and hence the more ready development of anaemia if other circum- 
stances coincide. In old age, on the other hand, the productivity is 
diminished, and hence the waste may easily exceed the demand if 
there be any disturbance either in the preparation of materials for the 
blood or in the retrograde metamorphosis of the tissues. There are 
those also who have a natural tendency to anaemia, a peculiar type of 
constitution. They are in a condition the opposite of plethora, are 
deficient in the amount and quality of blood, and seem to be unable to 
produce it effectively. Sometimes they are persons of full habit, but 
possess a lax fiber, and are pale and weak. 

A powerful exciting cause of anaemia is an insufficient supply of 
food. Again, the food being abundant, anaemia may be the result of 
poor digestion, and faulty and imperfect assimilation. The food abun- 
dant, and the primary assimilation active, anaemia may result because 
of a deficiency in the supply of oxygen to complete the cycle of pro- 
cesses terminating in healthy blood. When the products of digestion 
are pouring into the blood, oxygen is needed to burn off the effete, 
excessive, or improper materials, and to perfect the preparation of the 
new materials. Light is also necessary to this process. Moderate 
exercise, by increasing the rate of organic movements and the con- 
sumption of oxygen, favors the preparation of the blood and improves 

* " Pathological Chemistry," translated by Dr. S. T. Speer. London : Churchhill, 
1857. 



255 



its quality. The absence or imperfect supply of food, liglit, air, and 
exercise, impairs the vital processes and induces angeraia. Excessive 
exertion and fatigue, by the over-consumption of material, directly 
contribute to the production of the anaemic state. Heat acts similarly, 
in that prolonged high temperature increases the rate of circulation and 
the interchanges of waste and repair, while at the same time it inter- 
feres with supply by lessening the appetite and the digestion. Fre- 
quent repetition of the sexual orgasm, profuse menstrual flow, pro- 
longed lactation, haemorrhages, are very powerful causes of anaemia. 
Diseases of the organs concerned in nutrition, notably the digestive 
organs, malignant growths, albuminuria, the slow absorption of various 
mineral, vegetable, and gaseous poisons, and numerous pathological 
processes, either produce or are accompanied by anaemia ; but in this 
relation the position of anaemia is quite secondary. 

Pathological Anatomy. — The changes found ^:>os^ mortem in anaemia 
from haemorrhage are simply the appearances due to an exsanguine 
condition of all the organs and tissues. They are paler, drier, more 
compact, and free from blood. If death has been preceded by a wast- 
ing malady, not only is there the condition of bloodlessness, but the 
bodv is shrunken, the subcutaneous fat has disappeared, the muscles 
are thin, and the serous cavities contain more or less fluid. Patches 
of fatty degeneration occur in the muscular tissue of the heart — chiefly 
in the papillary muscles — and to the eye present the appearance of yel- 
low spots and stria3. A similar (i. e,, fatty) change is to be found in 
the intima of the great vessels, notably the aorta. Fatty change also 
takes place in the gland epithelium of various organs — the kidney 
epithelium, the hepatic cells, the gastric-gland epithelia, etc. The blood 
has a brighter tint than in the normal condition, due to a diminution in 
the number of red-blood globules, and in the quantity of haemoglobin. 
In the anaemia due to loss of blood, the amount remaining after death 
is much below the normal ; under other circumstances, the diminution 
may be but slight. The blood is also thinner, and has less power of 
coagulation, the clot lacking in firmness, whence it must be concluded 
that the fibrino-plastic substance and the fibrinogen are below normal. 

Symptoms. — The simplest and purest form of anaemia is that caused 
by sudden and considerable loss of blood, as from wounds of arteries, 
unavoidable and post-partum haemorrhage, etc. The symptoms are 
eminently characteristic : the skin becomes waxy white ; the sclerotic 
pearly and glistening, eyes sunken ; the face ghastly and shrunken ; 
the lips pallid and bluish and retracted over the teeth ; the nose pointed 
and cold ; the finger-tips white, waxy, and cold ; the surface of the 
body is cold, and the temperature reduced below the normal ; the 
pulse is small, very quick, exceedingly feeble, and may cease to be felt 
at the wrist ; actual fainting may occur ; consciousness restored, faint- 
ing may be repeated, and this may occur many times ; the attacks of 



256 



DISEASES OF THE BLOOD-FORMING ORGANS. 



syncope may be accompanied by epileptiform convulsions as in ani- 
mals bled to death (Kussmaul and Tenner *) ; death may ensue in the 
syncope, or there may be a gradual restoration, the first change for the 
better consisting in a return of the pulse at the wrist, followed by 
warmth of the surface. But the weakness is yet extreme, and fainting 
occurs from the least exertion ; or, when any effort is made, the face 
flushes, the heart beats rapidly, there is much oppression of the chest, 
and a sense of utter exhaustion. Excessive thirst is one of the immedi- 
ate results of loss of blood, but the appetite for solid food returns very 
slowly. The urine is necessarily small in quantity after haemorrhage, 
but the relative proportion of urea is increased. When restoration is 
taking place, the urea is less, the specific gravity of the urine falls 
below the average standard, until the normal state is reached. The 
most common form of anaemia is that induced by wasting discharges 
— prolonged lactation, for example — by disturbances in the function 
of nutrition — primary and secondary assimilation — by the cachexiae — 
notably the malarial. This form of anaemia may be called chronic^ 
while that already discussed is either acute or subacute. In chronic 
anaemia there exist pallor, or an earthy hue or fawn color of the skin, 
wasting to a greater or less extent, by disappearance of the subcuta- 
neous fat, and a flabby state of the muscles : the skin is wrinkled, dry, 
and inelastic, the hair and nails appear dull and lusterless ; the temper- 
ature of the surface below normal ; the cutaneous circulation, the ten- 
sion of the arteries, and the force of the cardiac contraction lowered ; 
the anaemia 'bruit audible at the base of the heart and over the great 
venous trunks ; sometimes a haemorrhagic tendency develops ; the 
function of digestion is wanting in energy, the appetite capricious, the 
bowels constipated ; the urinary secretion is rather scanty, and may 
contain albumen, etc. ; the sexual system is depressed, both male and 
female, and, while the sexual appetite is lessened in the male, amenor- 
rhoea is present in the female, or there may be menorrhagia. Not all 
anaemic persons become paler by reason of diminished vascularity of 
the skin; those of dark complexion and the dark-skinned become darker. 
The emaciation, or at least the lessened fullness and roundness of the 
form due to anaemia, may be supplanted by oedema, produced by the 
changes in the composition of the blood. When the diminution of 
albumen reaches a certain point, the fluid normally contained in the 
tissue is not taken up by the blood-vessels, whence more or less oedema 
results, and, under the same circumstances, accumulation of serum 
takes place in the serous cavities. In this process there necessarily 
exist both " hypalbuminosis " and "hydraemia" — the former meaning 
a diminished amount of albumen ; the latter, an increased amount of 
water. The hypalbuminosis is the most important factor in the pro- 

* " On the Nature and Origin of Epileptiform Convulsions, caused by Profuse Bleed- 
ing, etc," Sydenham Society translation. 



ANEMIA. 



257 



duction of the wasting or marasmus of anaemia. Not all parts lose in 
weight uniformly — the fatty tissue comes first, and next the spleen, 
liver, and voluntary muscles; and, as respects the muscular system, those 
waste least that are kept at work, as the heart and respiratory muscles. 
The weakness of the muscular system, which is so prominent a symp- 
tom in anaemia, is due largely to the diminished production of force, 
rather than to changes in the muscles themselves. The poor quality 
of the blood and the inactivity of the tissue-changes are the causes 
of the lessened evolution of force. A temperature below the normal 
is another result of the same causes. Among the most important of 
the symptomatic disturbances of anaemia are those of the nervous 
system. The organs of special sense are peculiarly alive to external 
impressions, and hence loud sounds, bright lights, and sharply sapid 
substances, make an unpleasant impression. The sensory and motor 
apparatus are similarly affected. Hyperaesthesia and hyperalgesia — 
neuralgia — are among the most disagreeable of the symptoms which 
occur during anaemia. Hysterical seizures, epileptoid attacks, are also 
results of an imperfect nutritive supply (" anaemia of the brain "). When 
the anaemia is extreme, as in cases of inanition, or from any cause, there 
is usually delirium, it may be, having a violent maniacal character, or 
low-muttering, or cheerful, busy delirium. The anaemia may result in 
syncope with temporary loss of consciousness — attacks frequently due 
to mere enfeeblement of the heart's action. As regards the condition 
of the organs of circulation, it is to be noted that the cardiac movements 
are feeble, the sounds mufSed and indistinct, and the arterial tension low. 
The diminished power of the heart to move the blood leads to stasis 
in the venous system, which may result disastrously by oedema of the 
lungs, or hypostatic pneumonia, or by thromboses. More or less diffi- 
culty of breathing is a constant symptom, but there may be extreme 
dyspnoea when some sudden effort is made. The impaired breathing 
power is the product of several factors : 1. Of the increased irritabil- 
ity of the respiratory centers ; 2. Of imperfect depuration of carbonic 
acid, and insufficient supply of oxygen. 

Course, Duration, and Termination. — The course of anaemia is that 
of the malady with which it is associated or on which it is dependent. 
If due to haemorrhage, or some sudden accident, it is acute, but the 
usual course is chronic. It has no defined duration, and is in no sense 
a self -limited disease. The progress of recovery is influenced by age, 
sex, and the recuperative powers of individuals. While women bear 
loss of blood better than men, they possess less restorative energy. 
The hygienic circumstances and the social condition are important 
elements in the process of reconstruction — for those who are most 
favorably placed have the best chance of recovery and the least delay 
in convalescence. Anaemia may result in death, in recovery, or in 
incomplete recovery. "When the anaemia has been extreme, and the 



258 



DISEASES OF THE BLOOD-FORMING ORGANS. 



destruction of red-blood globules great, recovery is rarely, if ever, com- 
plete, and the patient's bodily vigor remains more or less below the 
normal. 

Prognosis. — The cause of the malady and its associated states enter 
largely into the question of prognosis. When the anaemia is simple, 
due, for example, to sudden loss of blood, or to prolonged lactation, 
or to malarial infection, or to sexual disorders, or to diseases of diges- 
tion — all of which are perfectly remediable — the prognosis is favor- 
able. When, however, anaemia has been produced by excessive loss 
of blood, and a condition of extreme debility has persisted for weeks ; 
when associated with great mobility of the nervous system, and with 
protracted amenorrhoea, the prognosis must be guarded in respect to 
complete recovery. When anaemia is associated with cancer, albumi- 
nuria, suppuration of bone, amyloid degeneration, phthisis, scrofula, 
etc., the prognosis is unfavorable. 

Treatment. — As the condition to be remedied consists in an im- 
poverished state of the blood, obviously treatment must be directed 
to the organs concerned in the elaboration of blood ; the organs of 
digestion, including the liver and pancreas, and the organs for the 
production of the corpuscular elements — the spleen and lymphatic 
system. The first step consists in the rectification of any existing dis- 
ease of the digestive apparatus, if remediable ; the second, in the sup- 
ply of suitable aliment ; the third, in the administration of certain 
medicines needed in the construction of the blood ; and, fourth, in the 
admission of air, sunlight, and suitable exercise to an important place 
in the treatment, for these are required to perfect the final stage of 
the conversion of aliment into blood. If the digestion is feeble by 
reason of a deficiency of gastric juice, muriatic acid and pepsin should 
be administered after meals. If there be torpor merely, this may be 
overcome by the use of nux-vomica tincture, or the simple or aromatic 
bitters — these acting as local stimulants to the stomach-glands. If the 
appetite is languid and the stomach is equal to the digestion of the ali- 
ment taken, it will suffice to depend on the third group of remedies. 
A suitable supply of properly proportioned food is of the very highest 
importance. The albuminous or nitrogenous constituents — fresh animal 
food, eggs, milk, etc. — are the most necessary, but vegetables and 
fruits are also useful. If the digestive organs support food badly, it 
should be given in small quantity at short intervals, and, if solid food 
can not be managed by the stomach, beef-juice and milk can be given 
instead. The blood plasma may also be supplied directly by the rectal 
injection of defibrinated blood on the plan of Dr. Smith, of New York, 
which is a most important addition to our resources in the treatment 
of anaemia. A moderate quantity of alcoholic food is also highly ser- 
viceable — say, a tablespoonful of whisky three time a day — but it 
should always be remembered that a taste for alcoholic beverages is 



ANJEMIA. 



259 



quickly formed under these circumstances. The medicines required 
are those actually used in reconstruction of the blood, viz., iron, man- 
ganese, and the phosphates. As iron and manganese exist together 
in the blood (1 to 40), and also throughout nature, it is very useful 
to follow this indication and administer them together. There is 
another view of the utility of iron — promulgated chiefly by Brown- 
Sequard— that it acts solely by increasing digestion, and that the food 
taken in increased quantity under its use contains sufiicient iron to 
supply the requirements of the blood ; but the former view is that 
chiefly entertained. The saccharated carbonate of iron and manga- 
nese is an excellent preparation, or the dried sulphates of iron and 
manganese may be prescribed in pill-form, with or without extracts of 
nux vomica, gentian, or calumba. The question of the comparative 
utility of the vegetable or mineral-acid compounds of iron frequently 
arises. Notwithstanding the paradoxical character of the statement, 
it is generally true that the more irritating and astringent preparations 
are better borne, and they are certainly more effective. Next to iron 
and manganese are the phosphates, especially the phosphate of lime. 
In the anaemia of lactation there is a very marked deficiency in the 
quantity of phosphate of lime, and in all forms more or less reduction 
of the proper amount of this substance. The sirup of the lacto-phos- 
phate is the best form for the administration of this agent, if well 
and genuinely prepared. Pyrophosphate of iron may be given with 
the phosphates, as compound sirup of the phosphates ; or the elixir 
of the phosphate of iron, quinine, and strychnine may be prescribed 
under the same indications. 

When purpura, or the hsemorrhagic diathesis, or allied states of the 
blood exist, great advantage is derived from the conjoint administra- 
tion of ergot or digitalis with quinine ; for iron is not well borne 
when the haemorrhagic tendency exists, although the blood may be 
deficient in this constituent. Among the remedies for promoting the 
nutrition of the body, cod-liver oil takes a high place. It is usefully 
administered with the phosphates, especially in those cases in which 
anaemia is associated with impaired nutrition of the nervous system, 
and lowering of the general nutrition in cases of pulmonary disease. 
In the anaemia produced by phosphorus, carbonic-acid narcosis, coal- 
gas poisoning, etc., transfusion has been successfully employed. Unin- 
jured new elements introduced into the veins, the condition of anaemia 
is at once removed. The operation of immediate transfusion of human 
blood is alone justifiable under these circumstances, for lamb's blood 
will not functionate properly. When the food is undergoing final con- 
version into blood, the oxygen of the air is necessary to complete the 
changes. Hence some exercise, short of fatigue, should be taken 
about three hours after the meals, for at this time the products of 
digestion are pouring into the blood, and then the oxygen is espe- 



260 



DISEASES OF THE BLOOD-FORMING ORGANS. 



cially needed. Moderate exercise effects a proper distribution of the 
blood in the body, increases the absorption of oxygen, and the excre- 
tion of carbonic acid and urea. In proper limits exercise promotes 
the metamorphosis of tissue, and is therefore serviceable in anaemia, 
but, carried to fatigue, waste is greater than repair. The method of 
combined rest, massage, faradization, and forced feeding, practiced by 
Weir Mitchell,* is extremely useful in these cases, and will often suc- 
ceed when other means fail. 

CHLOROSIS. 

Definition. — Chlorosis and anaemia are usually regarded as identical 
disorders, but they differ sufficiently to be treated separately. The 
peculiarities of chlorosis are simply referred to the sexual condition, 
and it is therefore, according to this view, an anaemia occurring in girls 
about the period of puberty. The term chlorosis relates to the pecu- 
liar tint the complexion assumes in this disease, and in common lan- 
guage it is designated " green-sickness." 

Etiology. — Chlorosis is a disorder of the female sex almost exclu- 
sively, and those cases occurring in males are examples of modified 
anaemia. Puberty, or the period of sexual evolution, is the time of 
life when this disorder develops — from the fifteenth to the twentieth 
year. An inherited disposition seems to exist in many cases, for no- 
thing is more common than the references of the mother to her own 
experience when the daughter betrays the first signs of the malady. 
The type of constitution which is thus transmitted is distinctly of 
lowered vitality — " the gelatinous descendants of albuminous parents " 
is the apt phrase descriptive of the constitutional state. These sub- 
jects are light, fair, full, round, but white, having blue eyes, soft tis- 
sues, and feeble muscles. Menstrual irregularities seem closely asso- 
ciated with chlorosis, either as cause or effect. According to Virchow, 
abnormal narrowness of the aorta is an important factor. If an hered- 
itary predisposition exist, or congenital defects in the vascular system, 
the ordinary contingencies of social life may suffice to develop it — es- 
pecially the cultivation of the emotional life — but it occurs quite inde- 
pendently of erotic sentimentality. On the other hand, this condition 
of the system comes on without any apparent cause, or spontaneously. 
Hammond, who has made an elaborate study of chlorosis ("Journal 
of Psychological Medicine "), maintains that it is an affection of the 
nervous system, the blood-changes being secondary. 

Pathological Anatomy. — The body is fairly well nourished, and the 
subcutaneous fat pretty well distributed. The organs are generally 
pale. The serous cavities contain but little fluid, and there is no oedema 



" Fat and Blood, and how to make them." 



CHLOROSIS. 



261 



of the inferior extremities. The most important change occurs in the 
blood, and consists in a diminution of the red corpuscles. This can now 
be readily determined by actual count, using the hgemacytometer, as 
modified by Gowers, for this purpose. As the iron of the blood is re- 
duced in this disease, it is probable that the diminished staining power, 
which is so conspicuous an alteration, is due as well to diminution of 
the h?ematin as to loss of corpuscles. In chlorosis the albuminates 
and the leucocytes are not diminished, unless an anaemia develops in 
the course of the former, when the alterations peculiar to the latter are 
superadded. Neither is the volume of the blood apparently reduced. 
We owe to Virchow the important fact that in recurrent and persistent 
chlorosis, abnormalities exist in the vascular system : the aorta and 
arterial system, generally, are smaller in caliber, and thinner, the in- 
tima having a " trellis-like " arrangement ; and the tunics of the ves- 
sels are affected by fatty degeneration in spots, and stride of a yellowish 
color, especially the intima. These spots are found in greatest numbers 
about the origin of the ascending aorta, and on close examination are 
found to be a collection of minuter spots, each corresponding to a 
connective-tissue corpuscle, which is advanced in fatty degeneration. 
The heart may be normal, may be abnormally small, may be somewhat 
hypertrophied, but the alterations of this organ are not constant. The 
sj)leen, the lymphatics, and the marrow of bones, are not affected in 
any way. 

Symptoms. — Girls about the period of puberty are the subjects 
cf chlorosis. With or without disorders of menstruation, the affected 
person experiences a change in her feelings, and becomes morose and 
despondent, or capriciously vibrates from an extreme of high spirits 
to corresponding depression, but low spirits is the habitual state of the 
largest number. There is no reason to believe that erotic feelings are 
mixed up with the gloomy fancies which dominate the mind, but nym- 
phomania is in rare instances present as a symptom. Hysterical mani- 
festations may also occur, but do not constitute a necessary part of 
the malady. As respects the actual condition of the sexual organs, 
there are two forms of derangement which happen in chlorosis : there 
are the amenorrhoeic form and the menorrhagic form — cases in which 
the menstrual flow is absent ; cases in which the flow is excessive. 
After an attack of menorrhagia, or after the failure of the flow to ap- 
pear, the changes in the mental state above mentioned manifest them- 
selves. Then the complexion changes. Fair-haired and white-skinned 
girls (blondes) become pallid, and waxy, and puffy, but without 
oedema ; dark-haired and dark-skinned girls (brunettes) assume a 
muddy, grayish coloration, with bluish-black rings under the eyes ; 
the sclerotic being pearly and glistening, and the mucous membrane 
of the mouth pallid. There is present, constantly, a strong feeling 
of fatigue, and the least exertion causes weariness, while strong mus- 



262 



DISEASES OF THE BLOOD-FORMING ORGANS. 



cular effort induces exhaustion. Muscular effort of any kind starts 
the heart into tumultuous action, and brings on difficult breathing and 
a sense of oppression. The ansemic hndt heard at the base, and over 
the great vessels, exists in chlorosis as in anaemia. The pulse is rather 
full, but soft, the action of the heart irregular, the breathing not rhyth- 
mical, and a dry, barking, or noisy cough is not unfrequently present. 
The appetite is usually capricious — now satisfied with difliculty, now 
indifferent to food, but characterized by sudden desire for unusual arti- 
cles, or by craving for pickles, slate-pencils, chalk, etc. Attacks of 
cardialgia are frequent and severe, and may indicate the presence of a 
gastric ulcer — a not infrequent complication of chlorosis. 

Course, Duration, and Termination. — Tbe course of chlorosis is af- 
fected by the social circumstances, and the treatment still more, by 
the presence of the changes described in the vascular system. There 
are several important complications which affect the behavior of chlo- 
rosis. The first is anaemia, the development of which increases the 
gravity and adds to the duration. Phthisis develops in a considerable 
proportion of the cases, and in part doubtless because of the narrow- 
ing of the aorta. Perforating ulcer of the stomach is an occasional 
and very fatal complication. The explanation of its relation to chlo- 
rosis is, probably, the existence of fatty change in the intima of a 
stomach-vessel, thrombosis, and rapid solution of the mucous mem- 
brane. Chlorotic subjects — those affected with the changes in the 
tunics of the arteries, certainly — are very liable to attacks of endocar- 
ditis. Yirchow, to whom we owe our knowledge on the subject, has 
further pointed out that during pregnancy, and in the parturient state, 
they are apt to suffer from ulcerative endocarditis of a most malignant 
character. 

Paroxysms of hysteria and attacks of chorea are not infrequent, 
especially the former. Chlorosis is also a large and important element 
in the formation of exophthalmic goitre, but the cases are too rare to 
give this fact importance here. The duration of chlorosis is very un- 
certain. It is not a self -limited disease, and manifests no tendency to 
spontaneous cure. It may terminate in recovery, in partial recovery, 
or in some intercurrent malady, as pneumonia, typhoid fever, endo- 
carditis, perforating ulcer of the stomach, cerebral haemorrhage, etc. 
The prognosis is favorable for simple, uncomplicated cases, but must 
be guarded for cases which recur, as they may be examples of chloro- 
sis with vascular changes. 

Treatment. — As lessened haematin and haemoglobulin is the essen- 
tial element in chlorosis, the administration of iron is the main point 
in the therapy. The combinations of iron with a mineral acid (tincture 
of the chloride, sulphate, etc.) are usually more effective than the so- 
called mild preparations. The addition of manganese is useful, be- 
cause of the intimate association of these minerals in the blood-glob- 



PERNICIOUS ANEMIA. 



263 



ules. The utility of iron does not consist solely in supplying to the 
organism of the chloritic a material which is deficient, but in stim- 
ulating the appetite and the digestion, so that more food is taken and 
disposed of more easily. It follows that iron must be given in large 
doses in this disease, and experience is in harmony with theory on this 
point. Excellent results are obtained from the conjoined or simul- 
taneous administration of iron and the phosphates — notably from the 
pyrophosphate of iron and lactophosphate of lime. Again, many cases 
do better — the majority, within my observation — by the combination 
of iron with some agent having the power to exalt the cerebro-spinal 
functions, as arsenic and strychnia. An excellent prescription, not- 
withstanding the chemical incompatibility, is the pil. ferri carb. with 
arsenious acid or arseniate of iron ; or, Fowler's solution may be given 
separately, after the chalybeate. Strychnia, iron, and manganese sul- 
phates can be given in pill-form. Hammond, influenced by his theory 
of the nervous origin of chlorosis, holds that arsenic is the true rem- 
edy, and his experience supports his theory. The author has seen the 
best results from a combination of iron and arsenic, and this fact he 
urges upon the attention of his readers. A generous diet, out-door 
air, and moderate exercise, are essential elements in the therapy of 
chlorosis. The combined treatment of rest, forced feeding, massage, 
and faradization, advocated by Weir Mitchell in these cases, seems to 
succeed in many wonderfully. The measures above recommended, 
combined with suitable hygiene, rarely fail, however, to effect a 
prompt cure. No treatment will accomplish more than a temporary 
cure in those cases associated with changes or abnormalities in the 
vascular system ; for the chlorosis will recur from time to time, and 
possibly the case terminate at last with ulcerative endocarditis in the 
pregnant or parturient state. 

PROGRESSIVS PERNICIOUS ANEMIA— ESSENTIAL ANEMIA- 
MALIGNANT ANEMIA. 

Definition. — By the term progressive pernicious anmmia is meant 
a form of anasmia of most severe character, progressive and fatal, and 
accompanied, toward the termination, by a fever. 

Causes. — This disease occurs usually in women from fifteen to 
forty years, who have been repeatedly pregnant or subjected to debili- 
tating influences, as uterine haemorrhage, or to bad hygiene. It is 
not known why, in some cases, these etiologic factors will cause anae- 
mia, and, in a few rare individuals, excite the far more formidable, 
indeed malignant, ailment. 

Pathological Anatomy. — There is little or no emaciation due to the 
disease. There may be a good deal of fat under the skin, and the 
body may present an appearance of fullness and roundness, due to a 



264 



DISEASES OF THE BLOOD-FORMING ORGANS. 



general oedema ; but usually the oedema is about tbe ankles. The 
skin may contain petechise of a purplish or brownish tint, scattered 
over the trunk and limbs. There may be ecchymoses, having the va- 
rious colors characteristic of extravasated blood at different periods, 
and vibices, due to the same cause, and produced by pressure. There 
is more or less serum in the various cavities, and the organs generally 
are pale and bloodless. The changes in the heart and arterial system 
are the same as already described (see Anjemia), and consist in fatty 
degeneration of the cardiac muscles (papillary) and of the intima of 
the aorta and principal arteries. The alterations in the composition 
of the blood are also similar to those of anaemia, but they are more ex- 
tensive and profound. The volume of the blood is lessened, the red 
corpuscles are fewer, the albuminates of the blood diminished, and the 
fibrin is deficient. There is no constant disturbance in the normal 
ratio of the white and red corpuscles, although cases have been re- 
ported in which the leucocytes were increased. 

Symptoms. — The exact beginning of pernicious anaemia usually 
passes unnoticed ; an unwonted paleness, a sense of fatigue on the 
least exertion, hurried breathing, and palpitation of the heart, at length 
attract attention. This may be entitled the chronic form. In a few 
cases, happening during pregnancy, the onset is rather sudden, and 
extreme pallor, palpitation, and breathlessness on making any effort 
appear within a short period. The progress is comparatively rapid in 
both forms after the symptoms are fully developed, and in a short 
time the weakness is such that the patient is confined to bed, is unable 
to rise, and faints on attempting to assume the erect posture. Various 
local haemorrhages take place, as epistaxis, bleeding from the gums, 
menorrhagia, extravasations under the skin and into the retina. The 
haemorrhages into the retina are very common, and consist, on oph- 
thalmoscopic examination, of small, blackish, brownish, or yellowish- 
brown spots, or larger patches covering more or less of the fundus. 
They may, when very minute, not affect the vision, although present 
in great numbers ; but an extravasation in the retina of considerable 
size obscures the field of vision correspondingly (Immermann). Small 
extravasations or larger haemorrhages may take place in the brain, 
with the usual results. A constant symptom is fever, but it does not ap- 
pear until near the end of the case, and does not pursue a definite plan 
or type. When death is imminent, the fever not only ceases, but the 
temperature declines below normal, falling to 95° Fahr., or even lower. 

Course, Duration, and Termination.— Although pernicious anaemia 
has been separated from allied states, yet in its course and behavior 
it strongly resembles anaemia and chlorosis, especially the latter, or 
more closely a combination of the two. It seems, as it were, anaemia 
added to chlorosis, and the worst features of each fully developed. 
The duration is not self -limited, and hence varies greatly. The acute 
cases usually terminate within two months, but the more chronic ones 



THROMBOSIS AND EMBOLISM. 



265 



continue for three or four months. The mode of dying is by exhaustion 
usually, but life may be unexpectedly terminated by sudden paralysis 
of the heart, or by cerebral haemorrhage. In some instances the end has 
been reached by the condition known as "Kussmaul's Coma." Sudden 
unconsciousness occurs in consequence of cerebral capillary embolism 
(white-cell embolism ?), or from the development of acetone (acetonsemia). 

Diagnosis. — Pernicious anaemia is distinguished from anaemia and 
chlorosis by the severity of the symptoms ; from albuminuria by the 
absence of albumen from the urine ; from leucocythemia by the nor- 
mal condition of the spleen, liver, and lymphatics ; from Addison's 
disease by the absence of the bronzing. The prognosis is highly un- 
favorable, no cases of cure having been reported. 

Treatment. — There is no specific plan of treatment. The anaemic 
symptoms require iron ; but, if haemorrhages are occurring, iron must 
be discontinued, when arsenic, ergot, and quinia may be substituted. 
A generous diet and stimulants must be administered from the begin- 
ning. The best results have been obtained from the administration of 
phosphorus, and from arsenic given subcutaneously and in full doses. 

THROMBOSIS AND EMBOLISM. 

Definition. — By the term thrombus is meant the formation of a clot 
in a blood-vessel — an ante-mortem coagulation. The mechanism of 
its formation and the pathological changes associated with it are called 
thrombosis. A detached clot, or parts of a clot, or any new formation 
circulating in the blood-current, is designated an embolus^ in the plu- 
ral emboli., as fibrin embolus, fat embolus, pigment embolus, etc. The 
secondary obstruction and the changes consequent thereon, produced 
by an embolus, are known as embolism — as cerebral embolism, pulmo- 
nary embolism, etc. 

Causes. — The process of coagulation of the blood consists in the 
precipitation and consolidation of certain of its constituents, which, 
under normal conditions, remain fluid, When a blood-clot forms, the 
fibrino-plastic substance acts on the fibrinogenous, the former contained 
in the blood corpuscles, the latter in the liquor sanguinis. This forma- 
tion of fibrin, by the reaction between two other principles, is like the 
production of prussic acid by the reaction between amygdalin and emul- 
sin, or of the volatile oil of mustard, by myrosin and myronic acid. 
The formation of fibrin, or the coagulation of the blood, only takes 
place in the vessels when there occurs a slowing of the current, or 
when there is a change in the parietes of the vessels. In diseases 
characterized by abnormal increase of the fibrin {hyperinosis^^ should 
the blood-current be much reduced in rapidity and force, coagulation 
will take place. Thus in post-partum haemorrhage, a thrombus not in- 
frequently forms in the pulmonary artery. When the vis-a-tergo is 



266 



DISEASES OF THE BLOOD-FORMING ORGANS. 



weak, and an obstacle is placed in the capillary region in front, thrombi 
may form in the veins next the capillary system — as, for example, in 
the pulmonary veins, in chronic interstitial pneumonia ; in the renal 
veins, in parenchymatous nephritis, etc. Again, when vessels are 
divided, haemorrhage is arrested by thrombi which close the divided 
extremity. Thrombosis, the result of changes in the tunics of the ves- 
sels, is more frequent in relation to disease of the arteries than of the 
veins. Formerly the notion was entertained that phlebitis played an 
important part in the process of thrombosis and embolism ; that the 
intima was the seat of exudations and other products of inflammation 
to which the formation of a clot was immediately due, but it is now 
known that inflammation of veins is interstitial ; that the tunica intima, 
deprived of its nutritive materials, undergoes necrosis, and becomes a 
foreign body, about which coagulation of blood takes place. This, 
however, is a comparatively rare cause of thrombus formation, as this 
process occurs in the veins. It is in the arterial system that those 
changes take place which enter so largely into the phenomena of 
thrombosis and embolism — the results of endocarditis and endarteritis. 
The formation of vegetations in endocarditis, especially on the valves, 
is a fruitful source of embolisms. In endarteritis slow degenerative 
changes occur in the walls of the vessels, the internal layer (intima) 
becomes involved — thickened, roughened, necrotic — and then thrombi 
form. Any foreign body, as a needle introduced into a vessel, will 
induce coagulation and the gradual formation of an obliterating 
thrombus. An embolus is formed when a portion of a thrombus, de- 
tached from the parent clot, enters the blood-current. The density of 
the clot and its position are important elements in the detachment of 
emboli. The softer the clot the more easily it is broken up, and, if 
situated near to the entrance of a communicating vein, the more cer- 
tain a portion of it will be broken off from the main mass. The coni- 
cal shape which the thrombus assumes, projecting beyond the point of 
attachment to the intima, and floating freely at its end, are physical 
conditions favoring its separation. Besides the action of these forces, 
emboli are detached by coughing, vomiting, sudden jars, straining 
muscular movements, etc. After fractures an immense number of fat 
emboli may enter the systemic circulation, and now and then a phle- 
bolithe is a cause of obstruction ; cancer products may penetrate the 
blood and be distributed widely ; multiple embolisms may be caused 
by the entrance, from a depot of putrefactive matters, of putrid fer- 
ments ; and pigment emboli may be a product of malarial fevers. 

Pathological Anatomy. — Recent thrombi consist of soft, brownish- 
red coagula, either in the form of a plug which fills the vessel and 
entirely shuts off the circulation, or in a plaque or tablet attached to 
one side of the vessel-wall, permitting still a part of the blood to pass 
through. In the case of the latter, successive deposits of fibrin pro- 
duce a stratified clot, which may ultimately obstruct the vessel. When 



THROMBOSIS AND EMBOLISM. 



267 



a vessel is ligated, the clot formed does not extend beyond the first 
communicating vessel, but, when the thrombus is spontaneous, the 
coagulum may increase by successive deposition of material until it 
extends into a neighboring vessel. If a thrombus is suddenly formed, 
there will be a uniform distribution of the red and white globules 
throughout the coagulum ; if slowly formed, the mass will have a 
stratified arrangement, due to the adhesion of the white corpuscles to 
each other, and their accumulation along the walls of the vessel, and 
on the surface of the clot, so that, when a section is made of a throm- 
bus formed by successive deposition, it will be found to be made up 
by alternating layers of ordinary blood-clot and of white corpuscles. 
Thrombi are, therefore, of two kinds, stratified and unstratified. The 
first steps in the organization of a thrombus consist in a process of con- 
densation : the liquid disappears, the red globules lose their color, and 
the mass contracts an intimate adhesion to the intima of the vessel. 
Vessels are formed by the union and canalization of migrated white 
corpuscles (Rindfleisch), and the remainder of the thrombus consists 
of a fine reticulation of fibers and corpuscles, but the corpuscles have 
usually disappeared at the expiration of two months. Softening of 
the clot begins in the oldest part. There is no attempt at organiza- 
tion, and the delicate reticulation of fibrin breaks up into a uniform 
granular mass. The red globules lose their coloring matter, and, mixed 
with the other contents of the thrombus, form a white or yellowish- 
white fluid having the consistence of cream, and an appearance like 
" laudable pus," but differing from pus in structure, for on microscopic 
examination it is seen to be composed of albuminous particles, fat- 
molecules, and altered blood-globules. While the interior of the 
thrombus presents this puriform appearance, the exterior may have 
the brownish-red of the clot, and there may be various shades of color, 
representing various stages in the process of softening. When the 
process is complete there remains a puriform-like collection, in which 
no red globules remain undestroyed, and together with the white are 
transformed finally into fat-granules. An embolus derived from a 
thrombus will have the appearance belonging to the age and condition 
of the latter. The vessel in which it is lodged will be damaged at the 
point of lodgment, but in front and behind the embolus, will be healthy. 
The vessel may be completely or only partially obstructed. If com- 
pletely, coagulation will ensue behind the point of obstruction forming 
a thrombus ; if partially, successive depositions of coagulum will occur, 
and a thrombus will form about the embolus. The bifurcation of 
arteries is the usual point at which an embolus lodges. Its effects are 
not limited to the point of lodgment, but include the whole area nour- 
ished by the vessel, and the wider zone supplied by the branches re- 
maining permeable. The part receiving blood through the obstructed 
vessel at once becomes anaemic ; but the neighboring district is the 



268 



DISEASES OF THE BLOOD-FORMIXG ORGANS. 



seat of an active hyperemia, whicli is designated collateral hyperemia. 
One result of the increased pressure in this hypersemic area is the rup- 
ture of small or large vessels and extravasation of blood. If the ves- 
sel obstructed is small and not a terminal artery, the anastomoses may 
be sufficient to supply the anaemic district. If, however, the compen- 
satory circulation is insufficient or absent, the ischgemic part dies — un- 
dergoes necrobiosis^ gangrene^ or necrosis. The consequences follow- 
ing arrest of the circulation by an embolus depend largely on the 
position, still more on the size, of the obstructed vessel. Dry gangrene 
is produced by embolic blocking of a vessel of an extremity. In 
internal organs, especially the brain, centers of softening and fatty 
transformation of the tissue elements, and haemorrhagic extravasations 
in the area of collateral hyperaemia, are results of embolism. Besides 
the haemorrhagic extravasations, infarctions occur in the parenchyma 
of those organs supplied with Cohnheim's terminal arteries.* 

Symptoms. — The position of a thrombus or an embolus exercises a 
most important influence on the symptoms caused by them. When a 
thrombus occupies a vein of an extremity, oedema of all the parts be- 
low is a result, and, if the obstructed vein is adjacent to important 
nerves, excessive pain, or troubles of motility, will also be present by 
reason of the pressure of the distended vessel. Gangrene is not a 
result, since the nutrition of the parts is accomplished, although feebly 
and imperfectly, but moist gangrene may be produced if other injuries 
are superadded — as erysipelas, traumatism, compression, etc. A cure 
in such a case is in part effected by the collateral circulation, but in a 
truer sense by the canalization of the thrombus. Notwithstanding the 
similarity in the symptoms, caused by thrombosis and embolism re- 
spectively, there is a great difference in the time at which the phe- 
nomena manifest themselves : the symptoms of autochthonous throm- 
bosis come on gradually ; of embolism suddenly, with shock (Wagner). 
Two classes of symptoms arise — affections of nutrition, from the sim- 
plest disorder up to gangrene, and functional disturbances, proper to 
the organ affected. These symptoms are not ascertained with the 
same facility in all situations. In the extremities, every step in the 
local process is easily followed and interpreted, but in internal embo- 
lisms only those symptoms due to perversion or suspension of function 
are recognizable. Embolic obstruction of a member is announced by 
a sudden and often intense pain and a chill, with numbness, loss or 
diminution of tactile sense, coldness, pallor of the skin, and a feeling 
of deadness and weight, and paralysis of the muscles ; the pulsations 
wanting below, while above the obstruction they are full and strong. 
If embolic blocking of a vein in the brain, there occur defects of speech, 
hemiplegia, etc. ; if of a pulmonary artery, sudden difficulty of breath- 

* Wagner, op. ext. " Untersuchungen uber die embolischen Processe," von Dr. Juliua 
Cohnheim, Hirschwald, pp. 112. Berlin, 1872. 



TOPOGRAPHY OF THE CARDIAC REGION. 



269 



ing and sense of oppression, with, it may be, intense oppression and 
anxiety and death. Sudden attacks of amaurosis in puerperal fever, 
acute rheumatism, and pyaemia, are usually due to embolism of the 
central artery of the retina. Those organs not well supplied with 
nerves, as the liver, kidneys, and mucous membranes, do not offer dis- 
tinct reactions on embolic blocking of their vessels, and hence the 
symptoms are obscure.* If the immediate danger of an embolic ob- 
struction is past, even if the symptoms are very formidable, provided 
terminal arteries are not obstructed, they may disappear in some hours 
or days by establishing a collateral circulation. 

Treatment. — As all the symptoms are due to the obstruction of 
vessels by a blood-clot, the point in the treatment of special importance 
is to effect a solution of this obstructing material. Theoretically, 
ammonia possesses a solvent power, and in its use the author has had 
most striking results in the case of thromboses and embolisms of the 
brain. To accomplish the purpose in view, ten grains of the carbonate 
of ammonia may be administered in a tablespoonful of solution of the 
acetate, three or four times each day. As, however, the action must 
be slow, the point of contact being small, the remedy must be very 
persistently employed. The iodide of ammonium may be administered 
in a solution with the carbonate also, and usually with good results. 
Other alkalies possess the same power, but to a less extent. The most 
generally useful is the phosphate of soda, in drachm-doses, three times 
a day, used for many weeks. As, however, prompt and speedy action 
is needed to avoid the serious structural alterations which occur so 
quickly, the ammonia preparations are preferable to any other having 
the same effects. 



DISEASES OF THE HEART. 



TOPOGRAPHY OF THE CARDIAC REGION.— METHODS OF 
PHYSICAL DIAGNOSIS. 

The heart lies somewhat obliquely in the chest, behind the ster- 
num, and extends downward to the left, so that the apex-beat is 
below and a little internal to the left nipple, and between the fifth 
and sixth ribs. The position of the heart varies somewhat with the 
position of the subject : it gravitates downward and forward when 
the posture is erect ; backward and upward when the posture is recum- 



270 



DISEASES OF THE HEART. 




TOPOGRAPHY OF THE CARDIAC REGION. 



2n 



bent. In general terms, the base of the heart is opposite the upper 
border of the cartilage of the third rib ; the most inferior part of the 
right auricle and the apex rests on a line parallel with the upper bor- 
der of the sixth rib,* and in contact with the upper surface of the dia- 
phragm (Figs. 19, 20). 

It is important to note the position of the valves with reference to 
exterior points of the thorax. 




Fig. 20.— Posteeioe View.— 1, CEsophagus; 3, Aorta; 4, Eight Primary Bronchus; 5, Eight Pul- 
monary Artery ; 6, Ascending Vena Cava ; 7, Lungs. After Kiidinger. 



The aortic orifice lies under the junction of the cartilage of the 
third left rib with the sternum at its lower margin. The orifice of 
the pulmonary artery is at the left edge of the sternum, opposite the 
second intercostal space. The left auriculo-ventricular (mitral) orifice 
is somewhat less than an inch from the left margin of the sternum, 
and is beneath the third costal cartilage. The right auriculo-ven- 
tricular (tricuspid) orifice is under the center of the sternum, opposite 
the upper border of the fourth intercostal space. It follows that, if 
the stethoscope be placed on the junction of the third left costal car- 
tilage with the sternum, its circumference will bisect each of the car- 
diac valves. 

* Henle's " Handbucb," Dritter Band, " Gefassiehre," p. 38 ; also Riidinger, op. dt. 



272 



DISEASES OF THE HEART. 



The ascending portion of the arch of the aorta extends about one 
fourth of an inch beyond the right margin of the sternum, and the 
vena cava lies half an inch to the right of the aorta, both vessels being 
behind the right second costal cartilage and the first and second inter- 
costal spaces. The trunk of the pulmonary artery is beneath the ster- 
num, to the left of the middle line, and extending somewhat more 
than half an inch beyond the left border of the sternum. The trans- 
verse portion of the arch of the aorta comes into relation to the right 
pulmonary artery, the left primary bronchus, and the left recurrent 
laryngeal nerve, all of which pass under it. 

All the methods of physical diagnosis are applied to the study 
of the heart : 

By inspection, the position of the apex-beat, protrusion or retrac- 
tion with the apical impulse, area of impulse, abnormal position of 
impulse, abnormal pulsations in projDer position, or pulsation in new 
positions, the venous pulse in the neck, etc., may be perceived. 

J^j palpatio7i can be ascertained the character and force of the 
impulse of the heart, the rhythm of its movements, friction fremitus 
or thrill due to the vibration imparted by the rubbing together of in- 
flamed pericardial surfaces, and the purring tremor of certain lesions 
of the valves. 

To get the best indications from palpation, the hand well spread 
out should be applied to the precordial surface, with the patient erect 
and recumbent. Palpation should, in turn, be practiced at all points 
on the chest where any abnormal pulsation may be detected. 

'Bj p)ercussion, the area of cardiac dullness, superficial and deep, 
can be ascertained. By superficial dullness is meant that evolved by 
gentle percussion of the precordial region — of that part of the heart 
uncovered by the lung. This space is somewhat triangular in shape, 
and varies in size in different subjects. If only light percussion- 
strokes are made, that part of the lung coming forward on the heart 
is thrown into vibration, hence imparting the pulmonary quality to 
the tone. In determining the presence or absence of effusion into the 
pericardial sac, or hypertrophy, this superficial dullness has more sig- 
nificance than the deep. When strong percussion is practiced, the 
body of the heart is reached, the vibrations have a different character, 
and hence the production of deey dullness. The superficial dullness is 
not only more significant, but is also more easily determined. The 
condition of the pulmonary parenchyma, of the stomach and colon, 
and the degree in which the left lobe of the liver extends to the left, 
modify the deep dullness and increase the difficulty of defining it ac- 
curately. 

The position, shape, amount, and degree of the deep cardiac dull- 
ness must be noted. The relation of these modifying circumstances 
to morbid states of the heart will be pointed out when the individual 
maladies are under consideration. 



PERICARDITIS. 



273 



By auscultation we obtain the most exact information of the state 
of the heart. Certain facts regarding the normal condition of the 
organ must be clearly fixed in the mind in advance of the study of 
pathological states. That these may be the more readily compre- 
hended and remembered, all statements not immediately utilizable 
are avoided. 

The cardiac cycle, or the whole period of the heart's movement, 
has been variously divided, but it suffices for practical purposes to 
regard it as made up of four parts : 1st, the systole ; 2d, the short 
interval ; 3d, the diastole ; 4th, the long interval. If the durations of 
these periods, respectively, are expressed in tenths, they have the fol- 
lowing relations to each other : the systole, ; the first or short 
interval, ; the diastole, -f-^ ; and the second or long interval, 
Certain sounds coincident with the systole and diastole are audible on 
application of the ear to the chest. These sounds are designated the 
first or systolic sound, due to the muscular contraction and the tension 
of the mitral and tricuspid valves, and the second or diastolic sound, 
due to the sudden stretching of the aortic and pulmonary valves. The 
first sound, audible with the greatest intensity in the mitral area, 
toward the apex, is rather dull, low pitched, prolonged, but is well 
defined. The second sound is much shorter in duration, clear, abrupt, 
and high pitched, and is audible with the maximum intensity in the 
aortic area — at the base. 

The normal sounds of the heart are variously changed in disease — 
as to pitch, duration, quality, and rhythm. These modifications will 
be studied in connection with the maladies of which they are the 
signs. Doubling of the sounds, or reduplication, as it is entitled, may 
be a merely functional condition, or it may signify important struct- 
ural changes. This phenomenon has been referred to a want of syn- 
chronism in the actions of the tricuspid and mitral valves. By Gutt- 
mann it is held to be the separation into distinct sounds of the several 
elements which, combined, make up the first or second sound, respect- 
ively — a lack of synchronism in the contraction of the papillary mus- 
cles acting on the segments of the mitral or tricuspid valve. This 
explanation is accepted by many as an adequate explanation of the 
phenomenon. 

INFLAMMATION OP THS PERICARDIUM— PERICARDITIS. 

Definition. — The term pericarditis means an inflammation of the 
pericardium. The inflammation may be limited to the parietal or 
visceral layer, or to a part of either, or it may involve the whole of 
both surfaces. In the former ease, it is partial or circumscribed / in 
the latter, general or diffused. The inflammation may also be either 
aerate or chronic, 
20 



274 



DISEASES OF THE HEART. 



Causes. — Idiopathic or primary pericarditis may arise fi-om trau- 
matism or from cold. In those cases supposed to be produced by 
changes of temperature there is usually, probably, a diathetic condi- 
tion — as albuminuria — which escapes notice. Secondary pericarditis 
i3 more common, and is due to two causes : to an extension of inflam- 
mation from neighboring parts — pneumonia, left pleurisy, pulmonary 
tuberculosis, caries of the sternum or ribs, aneurism of the aorta, endo- 
carditis, etc. ; to the rheumatic dyscrasia. The dependence of peri- 
carditis on rheumatism has been very differently stated by the different 
authorities. That in about one third of all the cases this complication 
arises is the opinion of Bamberger, and is doubtless a close approxi- 
mation to the truth, but Thompson* says sixteen per cent. The 
severity of the cases, but not the position of the joints affected, has 
some influence in determining the frequency of the complication. The 
first attack is more liable to this complication ; the second attack stands 
next. In Thompson's forty-three -cases of pericarditis, twenty-five 
happened during the first attack and thirteen during the second. The 
author has seen three cases in which the pericarditis preceded the joint 
affection. Usually this complication arises during the period of great- 
est severity of the disease — during the second week, the favorite days 
being the ninth and tenth (Thompson). Pericarditis also occurs dur- 
ing the course of certain eruptive fevers, as scarlatina, variola, in puer- 
peral fever, in albuminuria, scorbutus, etc., but there are no numeri- 
cal data for an exact statement of the relative frequency. As regards 
the period of life in which pericarditis happens, there are differences 
in the two sexes — women being more liable during the period of pu- 
berty, thirteen to twenty, and men from twenty to thirty, the average 
being respectively nineteen and twenty-five (Thompson). Men are 
somewhat more liable to the disease than women, but the difference 
is slight. 

Pathological Anatomy. — In the first stage of the inflammation there 
are two pathological conditions present : an alteration of the tissue, the 
seat of the inflammation ; and an effusion into the pericardial sac. 
The inflamed membrane is marked by an arborescence of minute ves- 
sels, or is of a deep-red color, in consequence of the general stasis^ 
and contains here and there spots of extravasation from rupture of 
over distended vessels. The membrane becomes dull, cloudy, and at 
first dry, and also swells from interstitial exudation, and its resistance 
is diminished by the separation of the connective-tissue elements. The 
stage of hyperaemia and suspended secretion is of short duration — last- 
ing from a few hours to twenty-four, the shorter rather than the longer 
period. Rarely a case occurs in which there is no other than the in- 
terstitial exudation, no moist exudation on the surface, nor effusion 

* " St. George's Hospital Reports," vol. iv, p. 31. 



PERICARDITIS. 



275 



into the cavity. Usually, after a variable period of a few hours, the 
membrane which was dry becomes coated, especially the visceral layer 
about the origin of the great vessels, with an exudation of fibrinous 
substance, having, it may be, a thin, pellicular character, or thicker 
and more consistent, but soon extending over both surfaces. Some- 
times the exudation is reticulated, sometimes it forms conical or fili- 
form projections — pineapple heart, cor villosum, cor tomentosum^ etc. 
These peculiar appearances are due largely to the movements of the 
heart and the friction of the exudation on the two surfaces. When 
the exudation is sero-fibrinous, more or less straw-colored serum, having 
flocculi of lymph or masses of fibrinous substance floating in it, is con- 
tained in the cavity. Instead of being straw-colored the fluid may 
retain so much of the solid exudation churned up with it as to have a 
creamy consistence and a yellowish color ; or it may have a reddish 
tint from a slight admixture of blood, or be composed largely of blood 
(hgemorrhagic pericarditis). The serous fluid may also have a yellow- 
ish tint from the presence of leucocytes, or the exudation may have 
from the beginning a purulent character. The latter is the case in 
pericarditis occurring during pyaemia, puerperal septiciemia, variola, 
etc. The hsemorrhagic exudation occurs in chronic alcoholismus and 
in scorbutus. There are, therefore, sero-fibrinous, hsemorrhagic, sero- 
purulent, and purulent exudations. A strictly serous exudation is 
found in general dropsy, in dropsy of the pericardium, etc., but not in 
true pericarditis. 

Effusions may be entirely removed, even those consisting largely 
of solid exudation. The fibrinous matter breaks up into a granular 
mass, which gradually becomes fatty ; the cells also undergo a fatty 
metamorphosis ; the watery part is quickly taken up and the fatty 
emulsion undergoes slow absorption. A complete restoration of the 
parts to the normal may ultimately take place, but this is an excep- 
tional result. It is to be expected only when the exudation is largely 
serous, or when the fibrinous substance is deposited on a small extent 
of surface and is thin. Usually the watery part of the exudation is 
taken up ; the migrated white-blood corpuscles in the mass of fibrin- 
ous exudation assume a fusiform shape, unite end by end, and form 
canals or blood-vessels, and thus an exudation becomes organized. The 
epithelium takes part in these changes, by the proliferation of its 
cells, and the mass of solid exudation is composed not only of fibrinous 
substance, but migrated leucocytes, and proliferating epithelium, 
mixed with a basis substance, composed of germinal matter.* Pro- 
jecting masses of exudation, uniting from the two sides, form bands, 
which organize by the formation of vessels, and remain permanently. 
There may be a thin band or bands connecting the visceral and pa- 
rietal layers, or larger and broader bands which, uniting, form sub- 
* KiadflciscL, cp. nit, p. 265. 



276 



DISEASES OF THE HEART. 



divisions of the sac, or, the two surfaces may be glued together, en- 
tirely obliterating the cavity of the pericardium. The union may be 
so perfect that the most careful dissection can not separate them. 
Calcareous deposits may subsequently form in the exudation, or the 
whole of it may finally become so completely calcified, by the deposit 
of lime salts, that the heart is inclosed in an apparently bony case. 
The adherent pericardium is not unfrequently reported in medical 
journal literature as a congenital absence of this sac, and the calcifica- 
tion of an exudation, as the formation of a true bony envelope of the 
heart. The fluid exudation may persist notwithstanding the forma- 
tion of neo-membrane and bands of adhesion, and it changes in quan- 
tity, now increasing while fresh deposits of fibrinous substance is 
occurring, now diminishing with a temporary amendment ; some- 
times assuming a hjemorrhagic character, but more frequently becom- 
ing purulent. The more solid and unorganized exudation, crossed 
here and there by bands of adhesion, assumes a grayish color, and 
undergoes ultimately a caseous transformation. 

The muscular tissue of the heart becomes diseased by reason of 
the proximity of the inflammation — an acute myocarditis — which 
affects the muscular tissue in contact with the inflamed membrane. 
The muscular fibers become paler than normal, soften, and are infil- 
trated with fat-granules, so that the muscular contractility is impaired, 
and hence, if the lesion extends, the power of the heart will be greatly 
lessened. The extent of the pericarditis and the duration of the in- 
flammation have a material influence on the extent of the myocarditis. 
In hsemorrhagic and purulent exudations, the damage to the heart is 
greater. The strain on the heart due to the increased exertion re- 
quired in fever, and the compression of the exudation, interfering with 
the passage of the blood to the muscular tissue of the heart, also affect 
the nutrition of the organ, and favor degenerative changes. Endo- 
carditis may result by an extension of disease from the inflamed 
pericardium, as has been experimentally and clinically established. 
In chronic pericarditis the myocarditis persists, the walls yield to the 
blood-pressure, and the cavities, the right especially, dilate. 

Symptoms. — When an idiopathic pericarditis comes on, the initial 
symptoms occurring are those of any acute serous inflammation : 
tnalaise, chill, fever, increased respiration, loss of appetite, frequently 
nausea and vomiting. Pain of a dull, heavy character, or a feeling of 
soreness, is felt in the chest, but not invariably. Acute pain in the 
position of the pericardium is experienced only in those cases with 
pleuritis of the adjacent portion of the pleura, so that the real signifi- 
cance of any soreness or pain felt is ascertainable only on physi- 
cal exploration. When pericarditis is secondary to an existing dis- 
ease, there are no marked disturbances to indicate its onset — no dis- 
tinctive increase in the temperature and pulse-rate, or in the respiratory 



PERICARDITIS, 



movements, but there may be some prsecordial anxiety and oppres- 
sion, so that, in all cases of diseases in which inflammation of the peri- 
cardium is liable to occur, systematic physical exploration of the 
chest should always be practiced. 

The fever movement in simple idiopathic pericarditis is of the remit- 
tent type, but in the secondary disease it does not modify that of the 
existing malady. The state of the circulation varies from a condition 
of high tension, with full, strong pulse, to great feebleness, low ten- 
sion, and small, irregular, and unequal pulse. A weak, irregular pulse 
is characteristic only of cases with considerable effusion, with myo- 
carditis, or exhausted by the severity and duration of this disease. The 
rational signs of pericarditis possess but little value ; but the physical 
signs are highly significant. In the young, a small amount of effu- 
sion may render the prjecordial space prominent, but, in adults, only 
a large accumulation will push out the intercostal spaces sufficiently 
to produce bulging, unless the lung is shrunken, or there are pleuritic 
adhesions so situated as to prevent the outward expansion of the peri- 
cardium. When there is any considerable distention of the sac and 
anterior bulging, the nipple of the left side is thrown up higher 
than its fellow of the opposite side. In consequence of the effusion, 
the sac of the pericardium is enlarged, and the mobility of the heart 
on changes of position is increased. Hence, on palpation, this in- 
creased mobility is ascertained by the different positions in which the 
apex-beat can be felt. When the effusion is sufficient to force the 
heart to a more horizontal position, the apical impulse is farther out 
and upward. As the effusion increases, filling the sac, the apical im- 
pulse becomes weaker and weaker, and is finally no longer felt, as the 
fluid is interposed between the apex-beat and the chest-wall. When 
the systole of the heart is weakened by myocarditis, or exhaustion, 
the apical impulse disappears earlier, especially if there be interposed 
a thick layer of soft exudation ; on the other hand, the apex-beat will 
be felt longer when there is hypertrophy of the heart, and may not 
disappear at all if old adhesions keep the apex against the chest-wall. 
A change of position, as bending the body forward, may cause the 
apical impulse to be felt again when it had disappeared on the dorsal 
decubitus. On palpation, for a brief period may occasionally be felt a 
vibration of the chest-wall, due to the rubbing of the roughened sur- 
faces together. To develop this sensation, firm pressure must be made 
in the intercostal space with the finger-tips. It is exceedingly rare for 
this friction fremitus to be strong enough to excite vibrations of the 
chest-wall, which may be perceived by the hand laid on the prsecordial 
space. It is a rough, jarring, rasping sensation, similar to but quite 
distinct from the fi^emissement cataire^ or purring tremor, and is not 
exactly isochronous with the cardiac systole and diastole, although a 
to and-fro movement. 



278 



DISEASES OF THE HEART. 



The area of cardiac dullness is increased when the effusion is suf- 
ficient in amount. The enlargement of the area of relative dullness is 
more important in a diagnostic point of view, because there may be 
no change in the absolute dullness, even when there is considerable 
effusion. The diminished sonority is first perceived at the sternal 
end of the third and fourth ribs — at the base of the heart. The dull 




Fig. 21— Effusion into the Sac of the Pericardium. 



space has a triangular form, with its apex uppermost and base down- 
ward — the right line of the triangle extending from the apex at the 
second rib and sternum, along the right border of the sternum, and 
even beyond, to the right sixth and seventh ribs and sternum ; the 
base-line of the triangle passing through the seventh intercostal to 
the axillary border, and there intersecting the left line. When the 
effusion is extreme, the epigastrium is pushed outward by the descent 
of the diaphragm and the left lobe of the liver. The size of the trian- 
gular space is enlarged by sitting up and by bending forward. When 
the apex-beat can still be felt, and the area of dullness extends beyond 
it, this fact indicates that the sac of the pericardium is greatly dis- 
tended, and consequently forced beyond the apex, and is therefore an 
important sign of effusion. A change in the position of the dullness 
may be slightly effected by changing the decubitus of the patient, the 
fluid obeying the laws of gravity. The pressure of the lung in the 
neighborhood of the pericardium is a necessary result of the accumu- 
lation of fluid ; but this condensation is distinguished from effusion 



PERICARDITIS. 



279 



by tlie vocal fremitus, which is weakened or absent in the latter, but 
increased or normal in the former. In estimating the results of per- 
cussion, two sources of error may interfere : the dullness may be more 
extensive than the amount of the effusion v/arrants ; it may be less. 
The first is due to adhesions which have the effect to retract the lung 
from the pericardium, and to push the heart forward, thus enlarging 
unduly the area of absolute dullness ; in the other, the lung is attached 
anteriorly, and the heart lies deeply, and is still further depressed by 
the weight of the effusion. The pericardial friction murmur is the 
most significant of the physical signs of pericarditis, and is produced 
by the rubbing together of the two surfaces roughened by exudations, 
or by one roughened surface. This hruit makes the impression on the 
ear of scraping, grating, creaking, churning, and various modifications 
of these noises. They are, ordinarily, resolvable into three : the 
creaking of new leather, grating, or scraping. The sound may be 
partial or general ; it corresponds to the seat of the exudation, and is 
not confined to the situation of the orifices of the heart, but is heard 
with the maximum intensity at the third intercostal space on both 
sides of the sternum. The area over which it is audible depends on 
the extent of the exudation. The hruit accompanies the heart-sounds, 
but is not confined to them, and extends into the interval, and may 
indeed occupy the whole revolution of the cardiac movement. Hence 
the term " bruit de galops Usually or frequently, the bruit is pre- 
systolic, systolic, and diastolic — the presystolic corresponding to the 
auricular systole, and the others to the systole and diastole of the ven- 
tricles. When there is no effusion (dry pericarditis), there will be 
usually no rational symptoms of the malady — nothing but fever, and 
the physical signs of pericardial inflammation. 

The friction murmur, as well as the friction fremitus, occur early, 
and are recognized, if at all, within the first two days, and they persist 
for several days or weeks, according to the progress and amount of 
the effusion. They may decline in two or three days and disappear, 
as the effusion fills the sac and separates the two surfaces, so that fric- 
tion is no longer possible. If the effusion is absorbed, then the bruit 
will become audible again. When the silence of the bruit is due 
to adhesions, there will be no return of it when it ceases. With 
the increase of the effusion the heart - sounds become weaker, and 
finally are no longer heard in some cases ; but usually they continue 
to be audible, although very feebly. The character of the pulse, dur- 
ing pericarditis, has no special quality ; it may be but slightly elevated 
above the normal ; it may be very much accelerated ; its rhythm may 
be much altered. At the onset of the inflammation, the pulse may be 
strong, the tension high ; but this is not maintained, the pulse becom- 
ing weak, and the arterial tension low from depression of the vital 
powers and the occurrence of myocarditis. A large effusion exerts a 



280 



DISEASES OF THE HEART. 



mechanical pressure upon the great vessels within the pericardial sac 
— the aorta and pulmonary artery — and interferes with their proper 
filling. Also, as the veins can not empty their blood into the auricles 
fully, they are kept over-distended, and an abnormal fullness of the 
venous system in general is the result. Stasis of the venous system 
causes passive congestion of the lungs, bronchial catarrh, difficult 
breathing, cyanosis, and oedema. The venous congestion occurs in the 
brain, and is manifested objectively by headache, vertigo, epistaxis, 
etc. ; in the liver, causing enlargement of the organ and hypersemia of 
the portal system ; and in the kidneys, inducing albuminuria. Irrita- 
tion of the phrenic excites a most distressing hiccough. Difficulty of 
breathing, cyanosis, feebleness of the heart's action, are also produced 
by myocarditis, which is really an acute fatty degeneration. The 
heart's movements are not only feeble, but scarcely distinguishable ; 
the pulse irregular, intermittent, feeble ; the sounds of the heart are 
hardly recognizable, and the first sound is often absent ; the tempera- 
ture falls, the legs become (Edematous, and death soon closes the 
scene. When severe dyspnoea and cyanosis come on in the course of 
pericarditis, they are more frequently due to the damage done to the 
heart's muscle than to the mechanical effects of the effusion. Again, 
the same symptoms, in a less extreme degree, however, may be due to 
nervous disturbance— to irritation of the pneumogastric and phrenic. 
Dysphagia may be caused by pressure of the effusion on the oesopha- 
gus, and aphonia by pressure on the recurrent laryngeal nerve. 

Course, Duration, and Termination. — The course of pericarditis is 
not always upon a uniform plan, and there are peculiarities due to 
the causes and complications. Those cases arising in the course of 
puerperal septicaemia, scorbutus, or pyaemia, are shorter in duration, 
and greatly more fatal than those which are due to the rheumatic di- 
athesis. The duration is influenced by many circumstances. In sim- 
ple, uncomplicated cases, terminating in health, the effusion may be 
absorbed and recovery take place in from ten days to two weeks. 
When a case tends to recover, the severe symptoms subside, the fever 
and the difficulty of breathing cease, the appetite returns, and conva- 
lescence is established. When there is much effusion, and yet the ten- 
dency is toward health, the area of dullness lessens, the apical impulse 
returns, the friction murmur and fremitus reappear for a short period, 
the normal sounds are heard again, and, with these evidences of im- 
provement afforded by the physical signs, are also the rational symp- 
toms of cessation of dyspnoea, of fever, and return of appetite. In 
other cases the improvement is partial ; the rational and physical signs 
of pericarditis persist, and the subsequent history is that of chronic 
cardiac troubles. In other cases a fatal termination takes place early 
— in the scorbutic form with haemorrhage in a few hours after the well- 
defined symptoms come on ; in cases with large effusion, dyspnoea, 



PERICARDITIS. 



281 



delirium, etc., death will occur in a week or ten days ; in cases with 
myocarditis and syncopal attacks, according to the age and other cir- 
cumstances, a fatal termination may occur within the first two weeks. 
According to Thompson, the average duration of rheumatic pericar- 
ditis in St. George's Hospital is fifteen days. 

Prognosis. — Simple cases of pericarditis, and rheumatic pericardi- 
tis, are not often fatal, and a favorable prognosis may be expressed in 
a very large proportion. As an intercurrent disease, coming on in the 
course of certain grave maladies, it is is extremely fatal. Among 
these maybe mentioned scorbutus, pyasmia, puerperal diseases, Bright's 
disease, some of the eruptive fevers, pneumonia, etc. 

Diagnosis. — The differentiation of pericarditis from endocarditis, 
hydropericardium, and left pleurisy, presents some points of difficulty. 
The separation of the endo- and exo-cardial murmurs is often an affair 
of extreme nicety. Dropsy of the pericardium is to be distinguished 
from the inflammatory affection by the absence of fever, local pain, 
and friction murmur. The character of the fluid in any case is to be 
determined only by the concomitant circumstances. If the patient is 
scorbutic, it is probably hgemorrhagic ; if a subject of chronic alcohol- 
ismus, it may be haemorrhagic ; if the accompanying malady is pyae- 
mia, or a septicsemic process, it is probably purulent ; if rheumatism, 
it is sero-fibrinous ; if albuminuria, serous. The differentiation of 
exo- from en do -cardial murmurs is based on the character, quality, 
seat, and persistence of the sounds. The friction murmur is a sound 
of rasping, of crackling ; the endocardial murmur is softer, smoother. 
The friction murmur may be local or general, and has no constant rela- 
tion to the orifices of the heart ; the endocardial murmur is heard with 
maximum intensity within certain valve areas. The friction murmur 
is not regularly isochronous with the valve-sounds, or with the cardiac 
rhythm ; the endocardial murmurs are usually systolic or disastolic, 
or coincide with the rhythmic movements of the heart. The friction 
murmur continues where it began ; the endocardial murmurs are prop- 
agated in the direction of the blood-current— basal or apical. The 
friction murmur varies from one hour to another in intensity and ex- 
tent ; the endocardial murmurs remain constant. The friction mur- 
mur increases with pressure of the stethoscope on the chest-wall ; the 
endocardial murmurs are not affected by pressure. The friction mur- 
mur increases in loudness with the upright position and bending for- 
ward ; the endocardial murmurs are most distinct in the recumbent 
posture. The friction murmur disappears when the effusion reaches 
a certain amount, and reappears for a short time when absorption has 
taken place ; the endocardial murmurs are permanent. The friction- 
sound of pleuritis is synchronous with the respiration ; the pericardial 
is synchronous with the cardiac movements, or nearly so ; suspension 
of respiration arrests the former, but does not affect the latter. When 



282 



DISEASES OF THE HEART. 



that portion of the pleura in contact with the pericardium is the seat 
of inflammation, a friction murmur, synchronous with the cardiac 
movements ; in that case the distinction is impossible. In pleuritic 
effusion, as a rule, the dullness changes with the position of the pa- 
tient, and in the upright position is over the inferior part of the tho- 
rax. In pleuritis with effusion, all voice and breath sounds disappear; 
in pericarditis, they are unaffected, except in so far as the lung is dis- 
placed by the enlarging pericardium. In hypertrophy of the heart, 
the action is heaving, and the apical impulse is strong ; in pericardi- 
tis, with or without effusion, the impulse becomes weaker, and, as the 
effusion increases, the apical impulse will cease, or at least greatly di- 
minish in force. In hypertrophy the absolute, in effusion the rela- 
tive, dullness is increased ; and, as has been pointed out, dullness 
exists beyond the apex of the heart when the effusion is large. 

Treatment. — If the initial symptoms are recognized, a full dose of 
quinia sulphate should be administered, with a half grain of mor- 
phia, and the cinchonism should be maintained, by repeated smaller 
doses, for twenty-four hours or longer. When the evidence of effu- 
sion exists, there is no longer any indication for the use of quinia, 
since the inflammatory process has passed beyond control. The next 
object of treatment, and that which usually engages our attention at 
once, is the management of the exudation. There can be no question, 
at present, respecting the influence of ammonia salts in lessening the 
coagulability of the fibrinogenous substance. The carbonate should be 
given in solution of the acetate— five grains every two hours — when 
the exudation is forming, and to procure its disintegration and absorp- 
tion, thus preventing adhesions. 

When the initial symptoms make their appearance, if the patient 
is robust, six to ten leeches should be applied to the epigastric region; 
they should be allowed to fill and fall off, but the bleeding should not 
be encouraged. Dry cups may be applied to the same point, if the 
condition be that of debility. With or without previous abstraction 
of blood, if the patient is not depressed and the action cf the heart 
feeble, an ice-bag should be applied to the prsecordia during the initial 
period, but this expedient ceases to be useful when there is much exu- 
dation, and may be very injurious if the heart is weakened by myocar- 
ditis. When the time comes for the removal of ice, good results may 
be expected from the application of flying-blisters. As a condition of 
quietude of the diseased organ is a measure of the highest utility, rem- 
edies which slow the heart are necessary. Aconite-root tincture and 
veratrum-viride tincture may be given to quiet the heart before con- 
siderable damage has been done. When, however, the heart begins 
to flag, remedies of a depressing kind are not suitable, and then digi- 
talis becomes extremely serviceable, not only to lessen the work of 
the heart, but to promote absorption. The infusion is the best form, 



ADHESIONS OF THE PE'RICARDIUM. 



283 



and it should be given in a tablespoonful-dose every four hours. Tho 
absorption of a pericardial effusion may be hastened by the use of jab- 
orandi, or better, its active principle — pilocarpine — so administered as 
to act freely on the skin. But jaborandi is too depressing a remedy 
when the action of the heart is feeble, and the pulse is small and irreg- 
ular. Stimulant doses of quinia and alcoholic stimulants are very 
important when the powers are failing and syncopal attacks are occur- 
ring. Mechanical means are proper when the effusion into the peri- 
cardial sac is great and does not yield to the remedies proposed. 
Paracentesis of the pericardium has now been performed many times 
with success, so that it can no longer be regarded as a doubtful experi- 
ment. The hypodermic syringe may be used to ascertain the character 
of the effusion. The needle, as in the operation for capillary puncture, 
is inserted close to the border of the sternum, in the fifth intercostal 
space. The operation of paracentesis is required when the effusion is 
great, or when it is purulent. If the effusion returns repeatedly, it is 
safe practice to inject the tincture of iodine ( 3 ij — J iv) to prevent the 
reaccumulation. If the contents of the sac are purulent, the iodine 
should be used more freely ( 3 ij of the tincture, 3 ss potassium iodide, 
and f iv water). To avoid wounding the heart, the patient should be 
recumbent when the puncture is made. The disadvantages of the 
operation are, that it is rarely curative ; that it has caused a pneumo- 
pericardium ; that the fluid is quickly replaced, because of the less- 
ened extravascular pressure ; that haemorrhages take place by rup- 
ture of the thin-walled vessels of the neo-membrane.* Better results 
are claimed from the operation of paracentesis when a part of the fluid 
is drawn at a time, rather than all at once. When there is extreme 
debility, the patient may not be able to bear the loss of the blood- 
serum which pours into the sac after the removal of the fluid. It is 
highly important to maintain the powers of life by suitable alimenta- 
tion from the beginning. Stimulants should also be moderately ad- 
ministered at an early period, and be given freely when cardiac failure 
is threatened. The author has not mentioned the so-called sorbefa- 
cients, calomel, and iodide of potassium, because the first named has 
no influence over the inflammation, and is, besides, highly unfavorable 
to the process of repair, and the latter is useless, except locally. As 
the pericardium is a closed sac, and as effusions into it are not affected 
by diuretics, they have not been considered among the remedies. 

ADHESIONS OF THE PERICARDIUM. 

Adhesions of the two pericardial surfaces are results of pericar- 
ditis. They occur in a variety of forms : as narrow bands, as mem- 
braniform partitions, dividing the cavity into several smaller cavi- 
* Jaccoud, " Pathologie Interne," vol. i, p. 535. 



284 



DISEASES OF THE HEART. 



ties, and sometimes these secondary sacs contain exudation, in the form 
of a caseous mass, or dark-brown deposits, a product of altered blood. 
The adhesion may be total, so that after some years no line of union 
can be made out between the two surfaces. The mass of exudation 
uniting the surfaces may be converted into an apparently bony case 
enveloping the heart by calcareous deposition. Bands of adhesion may 
exist externally to the pericardium, and unite this membrane to the 
neighboring pulmonary pleura, to the pleura costalis in front, to the 
mediastinum, etc. As has been pointed out in the preceding chapter, 
an inflammation of the pericardium leads to acute myocarditis — an 
acute fatty degeneration of the muscular tissue. Hypertrophy and 
dilatation are among the results of adhesions. Opinions are divided 
as to the precise part played by the adhesions, but there can be no 
doubt that atrophy with hyperplasia of the connective tissue are results 
of the myocarditis, which, in turn, induces dilatation of the cavities. 
When the cavity of the pericardium is obliterated, and adhesions have 
been contracted to neighboring parts also, the heart works to great dis- 
advantage; but the most serious result is the interference with the nu- 
trition of the organ. On the other hand, there may be entire adhesion 
of the two pericardial surfaces, and the heart be not at all incommoded. 

Symptoms. — The disturbances produced by adhesions are mani- 
fested in rational and physical signs. The propelling power of the 
heart being diminished, stasis takes place in the right cavities, in the 
lungs, and venous system generally. There are therefore constantly 
present bronchial catarrh ; difficulty of breathing ; swollen liver and 
spleen ; gastro-intestinal catarrh ; urine scanty, high-colored, and albu- 
minous ; veins full, face cyanosed ; general dropsy. The apical im- 
pulse is either wanting entirely, or is a mere tremor ; the pulse is rather 
quick, but low in tension, and the volume varies in different beats. 
These rational symptoms are chiefly indicative of the degeneration and 
atrophy which have occurred in the heart-muscle. Other symptoms 
are caused by adhesions. One of the most important physical signs 
of pericardial adhesions is a depression with the systole of the heart 
at the place of the apex-beat. Instead of an elevation of the inter- 
costal space when the apex of the heart is tilted against it at the time 
of the systole, there occurs a depression, or drawing in of the chest- 
wall. There may also be, at the left of the sternum, several small de- 
pressions or " pittings " in the intercostal spaces. These depressions 
are frequently due to pericardial adhesions of the two surfaces, and to 
the parietal pleura ; but they may occur independently of this, as has 
been demonstrated by Friedreich, produced by causes which obstruct 
the downward movement of the heart toward the left, and the tilting 
of the apex upward, the lungs at the same time not coming forward 
sufficiently. A diastolic elevation of the chest-wall is the compensatory 
sign of the preceding elevation. When the force producing the other 



HYDROPERICARDIUM. 



285 



ceases to act, there is a rebound of the chest-wall, which, if not visible 
to the eye, may be felt on palpation. These two signs are highly sig- 
nificant, but their absence does not negative the existence of pericardial 
adhesions. It has already been stated that the area of absolute dull- 
ness is increased in those cases of adhesions which fix the heart against 
the chest-wall, and do not permit the organ to fall back, while at the 
same time the lung is prevented coming forward. If the heart is so 
fixed in position by adhesions, and is at the same time hypertrophied, 
and if the pericardium be adherent to the chest-wall, and to the spine 
behind, there must, of necessity, be produced the systolic depression. 
When the diastolic rebound (" diastolic concussion ") occurs, a syn- 
chronous or diastolic collapse takes place in the cervical veins. Much 
distended during the systole, they suddenly subside and even disappear 
during the diastolic rebound, for during this act the chest is expanded 
and the blood is drawn into the cavity. The importance of pericardial 
adhesions depends much less on the adhesions than on the changes in 
the heart-muscle. Adhesion bands connecting the two surfaces may 
exist without injurious effects. When hypertrophy takes place com- 
pensation ensues, and the heart is equal to its duties for many years. 
On the other hand, when the heart-muscle undergoes atrophic degen- 
eration, its propelling power is insufficient, venous stasis and dropsy 
follow, and then a fatal termination is near. The treatment in these 
cases must be directed to the nutrition of the heart-muscle. Hest 
must be enjoined ; the appetite and digestion must be improved by 
bitters, mineral acids, and the ferruginous tonics. The heart must be 
toned up by digitalis and iron, and by the judicious administration of 
quinia and morphia — the latter in minute quantity (yig of a grain). The 
author has seen the greatest advantage from the use of sulphate of 
iron (gr. j), sulphate of quinia (gr. ij), sulphate of morphia (gr. 
and digitalis (gr. j) in pill-form, three times a day. 

HYDROPERICARDIUM— DROPSY OF THE PERICARDIUM. 

Pathogeny. — By hydropericardium is meant an accumulation of 
water in the sac of the pericardium without the occurrence of inflam- 
mation. After death, especially from chronic wasting diseases, there 
will be often found in the sac an ounce or two of fluid, poured out at 
the time of the death-agony and immediately after. In dropsy, prop- 
erly speaking, the quantity of fluid may reach to one or two pints. It 
is a clear, yellowish, or straw-colored serum, usually, but it may present 
a somewhat turbid appearance from the presence of cast-off epithelium, 
or a bloody appearance derived from haematin. This fluid has the 
composition of the blood-serum, and its alkaline reaction, but does not 
contain the same relative proportions of its constituents. The albu- 
men is less than in the blood-serum, and also some of the salts ; but it 



286 



DISEASES OF THE HEART. 



contains the fibrinogenous substance which sometimes coagulates when 
exposed to air. Urea is found in this fluid in renal diseases, and it is 
stained with bile-pigment in cases of jaundice. The fluid, if large in 
amount, dilates the sac, and its walls become thinned by the pressure, 
and often present a sodden appearance when there has been a protracted 
contact of the fluid with the endothelium. The subserous fat is ab- 
sorbed by the pressure, and the areolar tissue is infiltrated with fluid. 

The causes of hydropericardium are twofold : mechanical and dys- 
crasic. Diseases or neoplasms,* that interfere with the return of blood 
through the veins, as tumors, obstructive pulmonary disease, emphy- 
sema, and dyscrasia, such as Bright's disease, cancer, and tuberculosis, 
are the principal etiological factors. 

Symptoms. — A small quantity of fluid will not produce sufficient 
disturbance to cause recognizable symptoms ; a large effusion will be 
recognized by the rational and physical signs, such as were described 
under pericarditis, with effusion. There is, of course, no friction mur- 
mur. The apical impulse becomes more and more feeble as the effu- 
sion increases, and it ultimately ceases to be felt. The heart-sounds 
grow more and more feeble, and may disappear entirely. The area of 
relative dullness greatly increases and extends finally beyond the region 
of apex-beat, and has the characteristic triangular form of dullness from 
effusion. The diagnosis of hydropericardium, from the effusion of peri- 
carditis, rests entirely on the history — the latter being due to inflam- 
mation, the former not. The prognosis of this malady is serious, not 
wholly because of the fluid, but on account of the conditions associ- 
ated with it. The treatment is directed to the removal of the fluid, 
and consists in the use of eliminants and mechanical means ; purgatives, 
diaphoretics, and diuretics are employed to procure absorption. Saline 
purgatives, compound jalap powder, elaterium, are given to diminish 
blood-pressure and the quantity of fluid ; squill, digitalis, and cream- 
of-tartar, to excite diuresis ; warm baths and pilocarpine to stimulate 
the skin. These means may be entirely successful in some few cases 
in Bright's disease, for example, but will have but little effect in cases 
of emphysema, tuberculosis of the lungs, and when the effusion is due 
to the pressure of a tumor. Aspiration is proper when life is threat- 
ened by the extent of the effusion, but there is danger of exciting peri- 
carditis and of the admission of air.f 

HYDROPNEUMOPERICARDIUM.— This form of disease differs 
from the preceding in that air or gas, as well as fluid, is present in the 
cavity. The fluid, when gas is also present, is composed of some de- 
composing exudation, of pus, or of blood. The first named is derived 

* "Transactions of the Pathological Society of London," vol. xxii, p. 123. 
f Roberts, " Paracentesis of the Pericardium." Philadelphia, 1880. An excellent 
work. 



MYOCARDITIS. 



287 



from pericarditis, the result of traumatism, or excited by an ulceration 
penetrating the cavity from the neighboring parts. The symptoms are 
physical. The space of absolute dullness is occupied by a tympanitic 
sound, except at the base, where it is dull from the presence of fluid. 
Change of the patient's posture alters the position of the dullness. The 
heart-sounds and the apical impulse are sometimes feeble and may not 
be perceptible, but are usually loud, splashing, and prominent. A pe- 
culiar, clanging, metallic character is imparted to the heart-sounds. 
The friction murmur has a rough, rasping, metallic resonance. Very 
remarkable sounds are produced by the churning of the liquid and air 
together by the heart-movements, and are designated "the water- 
wheel sounds." The functional disturbances produced by hydropneu- 
mopericardium are those of pericarditis, and need not therefore be re- 
capitulated. The prognosis is grave ; yet, of fourteen cases collected 
by Friedreich, only ten proved fatal. It has usually been regarded as 
more fatal than these figures indicate. It is probable that some of 
them were examples of the admission of air merely, and were not 
produced by the gas of decomposition. The treatment is that of peri- 
carditis. The presence of decomposing materials, or such an excess of 
gas or fluid as to exercise dangerous compression, justifies the employ- 
ment of the aspirator, and washing out the sac with an iodine solution. 

INFLAMMATION OF THE MUSCULAR TISSUE OF THE HEART 

—MYOCARDITIS. 

Definition. — The cardiac muscle is subject to attacks of inflamma- 
tion, as muscular tissue in other situations. The term myocarditis 
includes several morbid conditions of an analogous kind, but different 
in seat and also in progress. 

Causes. — The male sex is more liable than the female. The acute 
form is more common before than after thirty years of age. Myocar- 
ditis may occur during intra-uterine life, and then preferably on the 
right side, setting up important changes. It is supposed that chilling 
the body, suddenly, when in a warm and perspiring state, will cause 
this disease ; again, violent muscular exertion is said to have excited 
inflammation ; but these are very doubtful causes. In fact, nothing is 
definitely known of the influences setting up such a morbid process in 
the heart-muscle. As regards the secondary diseases, our information 
is more definite. It has already been pointed out that myocarditis is 
a result of pericarditis, the inflammation extending by contiguity of 
tissue. It results from valvular lesions also, and may be secondary to 
the acute infectious diseases — as typhoid, pyjemia, scarlet fever, etc. 
Inflammation and abscess may be the result of embolic obstruction 
of the coronary artery. 

Pathological Anatomy. — The muscular tissue itself, or its inter- 



288 



DISEASES OF THE HEART. 



vening connective tissue, may be the seat of tlie inflammatory action ; 
consequently there are two forms — parenchymatous and interstitial. 

parenchymatous may occur in two forms ; in isolated patches, 
or generally diffused. When a large part of the organ is attacked, 
there is a marked change in its appearance. The muscular tissue has 
a reddish color, is puffy in appearance, and the pericardium is spotted 
with points of ecchymoses, is cloudy, and coated here and there with 
a delicate exudation. The muscular tissue, on microscopical examina- 
tion, is found to be cloudy, granular, and swollen, and the striae indis- 
tinct or absent, or the fibers are broken up into granular fragments, 
are crowded with fat-granules, and ultimately are replaced by rows of 
fat-granules. When the change is far advanced, the muscle is brown- 
ish in color, and almost or quite pulpy in consistence. This change 
may extend over large parts of the organ, or may be confined to spots 
or isolated patches, and certain parts of the heart are especially apt to 
suffer, as the apex of the left ventricle, and, at the base, the posterior 
wall ; next, the aortic valves adjacent to the septum, then the papil- 
lary muscle, and, on the right side, the muscular trabeculse. 

Interstitial myocarditis also occurs in two forms : the suppurative 
and the sclerotic ; the former being acute, the latter chronic. Suppu- 
rative interstitial myocarditis usually coincides with the parenchyma- 
tous ; and, between the muscular elements disintegrating with acute 
fatty degeneration, is seen more or less extensive dissemination of pus, 
or distinct and isolated collections, or abscesses. When the suppu- 
ration is due to emboli, the purulent collections are small, and thera 
are usually several ; when the result of interstitial inflammation, there 
is usually a single large one. An abscess may rupture outwardly into 
the sac of the pericardium, or inwardly into the cavity of the heart. 
If situated in the septum, by the discharge a communication is estab- 
lished betAveen the two ventricles, or it may cause a rupture of a seg- 
ment of the semilunar valve, an example of which has fallen under 
the author's observation. Again, an abscess in the walls discharging 
into the ventricle, forms a sac which, bulging outwardly under the 
blood-pressure, becomes an " aneurism of the heart," so called.* The 
interior of such a sac becomes lined with successive layers of fibrin, 
which protects the cavity from rupture, but only for a brief period. 
When an abscess discharges into the pericardium, a fatal pericarditis 
results ; when the purulent matters and shreds of broken-down tissue 
enter the ventricular cavity, they produce the disastrous results of 
multiple embolisms.f Rarely, the pus is absorbed, and a mass of con- 

* " Transactions of the Pathological Society of London," vol. xix, p. 149 (with 
plate). 

f Ibid., vol. XX. " A case of abscess of the heart bursting into the left ventricle." 
Boy of eleven years had a fall and hurt his shoulder ; had delirium, wakefulness, and 
fever, and a very rapid pulse, but no cardiac symptoms. Died on thirteenth day. 



MYOCARDITIS. 



289 



nective tissue and a puckered cicatrix remain to indicate tlie nature 
of the disease. 

The chronic interstitial myocarditis is sometimes called sclerosis 
of the heart, or fibroid degeneration (Legg) of the heart. It consists 
in a proliferation — an overgrowth — of the connective tissue and an 
atrophy of the proper muscular elements. There may be small bands 
of connective tissue stretching between the muscular fibers, or larger, 
firm bands, or indurated masses, which take the place of muscular tis- 
sue entirely. These bundles or masses of connective tissue occur in 
the papillary muscle of the left ventricle and in the walls, but more 
toward the apex than at the base. Two evils result from the pres- 
ence of these bands and masses of connective tissue and from the re- 
sulting muscular atrophy : the propelling power of the heart is re- 
duced and stasis occurs in the venous system ; the walls yield at those 
places composed of the connective tissue, and form the so-called " par- 
tial aneurism of the heart." It is especially at the apex of the left 
ventricle (eighty-five in eighty-seven cases) that these aneurisms form. 
They vary in size from a pigeon's to a hen's egg, are irregular and 
divided by partitions and often have diverticula attached, and they 
contain old deposits of fibrin and recent soft coagula. The walls of 
these partial aneurisms are composed of the sclerotic material, the en- 
docardium, and the visceral layer of the pericardium with, it may be, 
the parietal layer attached.* 

Symptoms. — The existence of myocarditis can hardly ever be any- 
thing but a presumption, based on negative rather than positive signs. 
If maladies are present, as rheumatism, pyaemia, puerperal fever, etc., 
in the course of which myocarditis may be expected, if the symp- 
toms of cardiac failure come on suddenly, and if they can not be 
referred to an endocarditis or pericarditis, then the existence of in- 
flammation of the heart-substance may be suspected. When this dis- 
ease occurs as secondary to rheumatic endo- or pericarditis, the patient 
passes rapidly into that condition of profound adynamia known as the 
typhoid state. When an abscess discharges its contents into the cavity 
of the heart, the symptoms of multiple embolisms are produced ; there 
are repeated violent chills, very high febrile temperature, profuse 
sweats, icterus, swollen spleen, albuminuria, delirium, or the disturb- 
ances due to embolism of the cerebral vessels, etc. The yielding of 
the sclerosed tissue and the formation of the so-called aneurisms are 
announced by failure of the heart ; the pulse becomes thready, the 
lips blue, the face anxious, livid, and cyanosed, the respiration em- 
barrassed, the surface cold, the weakness extreme, death occurring in 
a short time in syncope. 

Those cases of myocarditis in w^hich the symptoms of embolism 

* Ponfick, Virchow's Archiv;' Band Iviii, p. 528. 

21 



290 



DISEASES OF THE HEART. 



are wanting, and aneiirismal dilatations have not occurred, are char- 
acterized by the presence of the following signs : The movement of 
the heart is feeble, and the apical impulse unfelt ; the pulse is small, 
weak, irregular, and intermittent. The great diminution which has 
taken place in the propulsive power of the heart manifests itself in 
stasis, pulmonary engorgement and oedema, cyanosis of the face, swol- 
len veins, vertigo, delirium, etc. In the so-called chronic partial aneu- 
rism, there may be no symptoms for a time to indicate the existence 
of the lesions. We have here the same groups of symptoms, due to 
the diminished propelling power of the heart, as in the preceding 
paragraph, when sufficient damage has been done to causo yielding of 
the cardiac wall. 

Course, Duration, and Termination. — The course of the acute form 

of myocarditis is very rapid, and the duration from two or three to 
eight days, but some of them terminate in a few hours. Death may 
be due to rupture of the heart, to cerebral emboli, to pulmonary oedema, 
to paralysis of the heart, etc. Chronic myocarditis pursues a very 
latent course. The development of the lesions may be slow, and 
hence the duration may be prolonged, but not indefinitely. Dilata- 
tion of the cavities, feebleness of action, and stasis, will bring on 
fatal lesions in a few months, or, at most, a year or two. 

Treatment. — The treatment must be largely symptomatic, and for 
parenchymatous carditis is to the last degree inefficient, since the 
causes are not to be removed. Interstitial inflammation, like the same 
disease elsewhere, is little influenced by remedies. Minute doses of 
chloride of gold, or of corrosive chloride of mercury, quinioe, and 
digitalis, offer the best prospect of improvement. The utmost qui- 
etude of mind and body must be maintained. A generous diet and 
means to promote digestion are necessary to improve the quality of 
the blood. 

FATTY DEGENERATION OF THE HEART. 

Definition. — A distinction must be drawn between fatty degenera- 
tion and fatty substitution : the former implying a change in the struc- 
ture of the muscular tissue; the latter, a displacement of the muscular 
tissue, in which atrophy of the muscular elements may take place, by 
the pressure. 

Causes. — The nutrition of the heart is impaired by a variety of 
causes, intrinsic and extrinsic. Among the intrinsic are pericarditis 
and myocarditis, which set up an inflammation of the heart-muscle ; 
diminished blood-supply due to atheroma ; compression, etc., of the 
coronary arteries ; fat substitution, which, encroaching on the proper 
tissue of the organ, causes absorption, etc. Among the extrinsic 
causes are impaired nutrition in general, originating in various ways — 
cancer, tuberculosis, scrofula, prolonged suppuration, prolonged lac- 



FATTY HEART. 



291 



tation, etc. Most of the foregoing causes induce atrophy by setting 
up a fatty degeneration. Anaemia, especially when extreme and long- 
continued, has a strong tendency to induce this change. This has 
been demonstrated experimentally by Perl,* and clinically by Ponfick f 
and others. In the various causes above given it is the condition of 
anaemia induced by them which is responsible for the changes in the 
heart's muscular tissue Infectious diseases, fevers, and certain poi- 
sons, notably phosphorus and alcohol, bring on fatty degeneration. 
The same result is produced by the mineral poisons in general, but to 
a less degree, and some other substances. Fatty deposition sometimes 
takes place to a dangerous extent in the obese, along the sulcus, and 
penetrating to the endocardium. Furthermore, in the antemia of the 
obese, sometimes a very marked condition — fatty degeneration of the 
heart-muscle — comes on. 

Pathological Anatomy. — The change may be general or diffused, or 
exist in sjjots and patches. The color becomes yellowish, the tissue 
soft and easily torn, and on the touch makes, in advanced cases, a dis- 
tinctly greasy impression. The initial change is in the primitive bun- 
dles, which become cloudy, granular, and their striae disappear. Minute 
oil-globules appear, and are soon seen in rows, but they presently 
coalesce ; large globules are formed, and nothing is then visible in the 
sarcolemma but a multitude of fat-drops. With this change in the 
fibrillse of muscle, an (edematous condition of the sub-serous connective 
tissue occurs, and the nutrient vessels are advanced in calcareous de- 
generation. The fatty change may occupy the walls of the left ven- 
tricle, or be confined to isolated patches here and there in the walls of 
the heart, the papillary muscle, the trabeculse, the septum, etc. In 
the cases of fatty substitution, the whole heart may be enveloped in a 
dense layer of fat, which also pushes its way into the muscle, follow- 
ing the inter-muscular planes and the connective tissue, causing such 
compression that the muscular fibers undergo atrophy, and are pale, 
thin, and wanting in contractile power. 

Symptoms. — Weakening of the heart, produced by fatty change in 
its muscles, causes the disturbances due to senemia of the organs and 
to venous stasis. The rational are more significant than the physical 
signs. On palpation, the apical impulse is weak. On percussion, there 
is nothing distinctive, except an increase of the area of absolute dull- 
ness, if the organ is enlarged by dilatation of its cavities. As there is 
venous stasis, and as the right cavities yield more than the left, the 
area of dullness is increased over the lower end of the sternum to the 
xiphoid appendix. On auscultation, if there be fatty degeneration of 
the papillary muscle, a systolic murmur is audible in the mitral area. 
The sounds of the heart are dull, confused, almost inaudible, and there 

* " Ueber den Einfluss der Anamie auf die Ernahrimg des Herzmuskels," Yirchow's 
" Archiv," Band lix, p. 39. 

f Ponfick, " Berliner klin. Woch.," " Ueber Fettherz," Nos. 1 and 2, 1873. 



292 



DISEASES OF THE HEART. 



is often a failure of synchronism in the closure of the valves, causing 
double sounds. The pulse is small, irregular, intermittent, weak, and 
easily compressed, and may be very slow, falling to forty, often even 
as low as twenty ; but this is exceptional. A very formidable symp- 
tom, which, however, occurs under other circumstances, is a peculiar 
alteration of the respiratory rhythm, known as the Cheyne-Stokes 
breathing, in which at intervals the respiration becomes slower and 
shallower, until finally it seems to cease — is suspended for some sec- 
onds, half a minute, for a minute — and then is resumed, slow and shal- 
low, but gradually attaining its normal amplitude. This may be kept up 
for some time, then disappear, to occur again. The diminished propul- 
sive power of the heart, causing anaemia of organs, induces character- 
istic symptoms. Sudden anaemia of the brain, faintness, and actual 
fainting, often occur on rising up suddenly from a recumbent pos- 
ture, stooping, turning around quickly, etc. These subjects experi- 
ence constantly, or nearly so, a sense of fullness and distention about 
the ensiform cartilage or lower sternum, which is associated with prae- 
cordial anxiety, and they have attacks of angina pectoris.* They 
experience difficulty of breathing on slight exertion, and can not ascend 
elevations or stairways without experiencing great distress. The veins 
of the neck are habitually distended, and the countenance looks dusky 
and anxious. The legs become (Edematous ; next, the body generally; 
the liver enlarges, ascites forms, the urine becomes albuminous, etc. 

Course, Duration, and Termination. — Acute fatty heart, produced 
by the action of poisons, terminates early ; but the cases due to the 
ordinary causes proceed more slowly, and may last during several 
years. Their development is obscure, and there are no pronounced 
symptoms until those of failing heart come on. The termination is in 
general dropsy, or death is caused by oedema of the lungs, or takes 
place suddenly by paralysis of the heart, or by rupture of the organ. 

Diagnosis. — If the causes of fatty degeneration have existed, and 
symptoms of cardiac weakness come on slowly, the existence of fatty 
heart may be regarded as probable, but the diagnosis is largely the 
balance of probabilities, and is not to be arrived at by exclusion with 
certainty. 

Treatment. — As anaemia plays so important a part in the causation 
of fatty degeneration of the heart, the treatment should be directed to 
the enrichment of the blood. Iron, manganese, and strychnine (the 
sulphates), is an excellent combination. The author has seen good 
results from the phosphate of iron, quinia, and strychnia, in the form 
of the elixir. Jaccoud prefers caffeine to digitalis as a heart-tonic in 
these cases ; See urges its use in the same condition, and the author has 
found it to be as excellent a remedy as its advocates assert. It must, 
however, be given in sufficient doses, from five to fifteen grains ter in 
* J. Lockhart Clarke, " St. George's Hospital Reports," vol. iv, p. 1. 



RUPTURE OF THE HEAET. 



293 



die. The efficacy of opium, or, better, small doses of morphine, as a tonic 
of the heart, is too little understood, especially in the form of hypo- 
dermatic injection. Inhalations of oxygen gas, the internal use of 
cod-liver oil, and general faradization of the muscles, are expedients 
of high utility. iS^itro-glycerin is a remedy of the greatest value in 
these cases, or when the heart is weak from any cause. By lowering 
the peripheral tension of the vascular system, it lessens the work of the 
heart, and thus obviates a serious danger. By dilating. the arterioles of 
the muscular substance of the heart, it promotes the nutrition of the or- 
gan, and in this consists one of the most valuable results of its adminis- 
tration. It relieves the sense of precordial distress, the faintness and 
vertigo, and other unpleasant consequences of the cerebral anaemia. 

RUPTURE OF THE HEART. 

Definition. — Under the designation of rupture of the heart is meant 
the so-called spontaneous rupture, in contradistinction to ruptare by 
wounds and injuries. 

Pathogeny and Symptoms. — That rupture shall occur it is necessary 
that the walls of the heart be weakened by disease. The most fre- 
quent cause is fatty degeneration, for, in twenty-four cases, this condi- 
tion of the muscular tissue was found in nineteen.* ]^ext in impor- 
tance as a cause is the softening produced by acute myocarditis, espe- 
cially the suppurative form, or the aneurisms, so called, due to the 
changes of chronic myocarditis. Diseases of the coronary artery, 
tumors, echinococci, by destroying muscular tissue, lead to rupture. 
It is more common in men than in women, and in old age — after sixty 
years. As to the site of the rupture, statistics show that the left ven- 
tricle, at or near the apex, next the right ventricle, then the right 
auricle, are the most usual ; but the preponderance is immensely on 
the side of the left ventricle — forty-three times in fifty-five cases. 
There is usually but a single rent, but there may be several, and, as 
they follow the direction of the muscular bands and the line of least 
resistance, they are tortuous, somewhat jagged in their margins, and 
the two orifices are not opposite. The size of the rent varies from an 
inch to the whole length of the cavity. The pericardial sac contains 
more or less blood, according to the size of the opening. The rupture 
may be gradual, a part yielding at a time. Death may take ]3lace 
almost instantaneously. Usually, a groan or a cry is uttered, the face 
grows deadly pale, the individual falls unconscious, there is some shud- 
dering, and he is dead. - The dying may extend over several days — 
the patient experiencing the symptoms of angina p)GGtoris several 
times with intervals of partial relief, death occurring suddenly at last. 
In such cases, it is assumed that successive portions of the heart-wall 
yield, or that clots temporarily obstruct the rent. 

The treatment, when there is time for it, is purely symptomatic. 

*" Berliner klinische Wochenschrift," 18v3, p, 15 ; Ponfick, "Ueber Fettherz." 



994 



DISEASES OF THE HEART. 



HYPERTROPHY AND DILATATION OF THE HEART. 

Definition. — By hypertrophy of the heart is meant an increase of 
size of the organ, because of an addition to its substance. This en- 
largement takes several directions, as follows : 

Simple hypertrophy means an increase in size without alteration of 
the cavities ; concentric hypertrophy means increase in thickness of 
the walls, the cavities becoming smaller ; excentric hypertrophy means 
increase in the thickness of the walls, the cavities becoming larger. 

The dilatations of the heart correspond in arrangement as follows : 

In simple dilatation, the cavities are enlarged while the walls re- 
main normal ; in active dilatation, which corresj^onds to excentric 
hypertrophy, the cavities are enlarged, and the walls are increased in 
thickness ; in passive dilatation, the cavities are enlarged and the 
walls are thinner. This is the most usual form. 

The conditions attendant on hypertrophy and dilatation are, in 
some respects, the same, so that it is an economy of space, and con- 
tributes to clearness of conception, to study them together. 

Causes. — Hypertrophy. — Simple hypertrophy, which is by no means 
common, arises from over-action of the cardiac muscle, without there 
being any disease of the circulatory apparatus. The over-action is due to 
the abuse of such stimulants as coffee^ tea, tobacco ; to moral emotions 
and intellectual effort, when excessive ; to repeated muscular fatigue, 
etc. The hypertrophy resulting in this way is general. Any obstacle 
to the free circulation of the blood imposes additional work on the heart. 
Narrowing of the aortic orifice gives the left ventricle more work to 
do, and hence its muscular fibers undergo hypertrophy ; in the same 
way, hypertrophy of the right ventricle results from narrowing of the 
pulmonary orifice, of the left auricle, from mitral stenosis, and of the 
right auricle, from tricuspid stenosis. These are typical examples of 
partial hypertrophy. The causes of obstruction in front, inducing hy- 
pertrophy of the left ventricle, are several : stenosis and regurgitation 
at the orifice of the aorta ; narrowing of the artery at the duct of Botal ; 
aneurism, and compression of the vessel by tumors ; atheroma of the ar- 
terial system. Hypertrophy of the left auricle results from obstruction 
and regurgitation at the mitral orifice, especially narrowing of the ori- 
fice. Similar causes produce similar effects on the other side. Hyper- 
trophy of the right ventricle is due to narrowing of the pulmonary 
orifice, to aneurisms, and tumors compressing the artery, to chronic pul- 
monary diseases which obstruct the circulation, as emphysema, caseous 
pneumonia, fibroid lung, large pleural accumulations, etc. Hypertrojfhy 
results from, or is an attendant on, Bright's disease. Various explana- 
tions have been offered of the nature of this relationship, but it is clear 
that, if hypertrophy of the muscular layer of the arterioles exist in front, 
the heart has increased resistance, which requires additional effort to 
overcome. Hypertrophy is, so to speak, a physiological result of the 



HYPERTROPHY AND DILATATION. 



295 



chacges in the arterial system due to age ; for the calcareous deposition 
in the tunics of the aorta and of the vessels generally greatly increases 
the resistance of the arterial circuit by diminishing the elasticity. 

Dilatation. — Simple dilatation of the heart occurs in delicate consti- 
tutions, especially of growing youths, subjected to over-exertion. This 
has been observed in armies on a large scale, and by civil physicians as 
well.* Maclean \ has published observations on this point made in the 
English service ; Seits and others in Germany ; but Da Costa was the 
first to set the subject in its true light, by studies in our hospitals dur- 
ing the late rebellion, and preceded all other investigators in this line. 

The right ventricle, being much feebler than the left, is more liable 
to suffer dilatation. This condition results from the increase of pres- 
sure due to insufficiency of the semilunar and tricuspid valves, and 
pulmonary lesions which hinder the circulation in the pulmonary capil- 
laries, such as emphysema, chronic bronchial catarrh, chronic intersti- 
tial pneumonia, and tubercular and caseous infiltration. On the left 
side the most frequent cause is aortic obstruction and insufficiency ; 
but obstruction rather than insufficiency is more certain to produce the 
dilatation. Mitral insufficiency leads to dilatation of the right cavities 
by maintaining constantly an increased pressure in the pulmonary 
capillaries. The cavities yield under normal pressure of the blood 
when altered by disease. Pericarditis and endocarditis affect the con- 
dition of the muscular tissue, by setting up a myocarditis — a granular 
degeneration. Myocarditis arises under other circumstances also, and 
the heart-muscle is weakened, not by this disease only, but by fatty 
degeneration, fatty substitution, tumors, etc. 

Pathological Anatomy. — In hypertrophy the change may be con- 
fined to one part, or the whole organ may be involved. To such enor- 
mous proportions does the heart attain sometimes as to be called cor 
hoviniim — ox's heart. The walls of the left ventricle may increase to 
an inch, an inch and a half, or even two inches in thickness, and the 
walls of the other cavities undergo corresponding development. The 
shape of the heart is altered by hypertrophy. When there is hyper- 
trophy of the right ventricle, the heart is widened transversely and 
the apex is blunted ; when the left ventricle is enlarged, the heart is 
elongated, and, if its cavity is at the same time enlarged, the septum 
is pressed over into the right ventricle. When both ventricles are 
enlarged, the heart assumes a globular shape. The position of the 
liypertrophied heart is more horizontal ; if the left ventricle is the seat 
of the change, the direction of the organ is to the left and downward. 
By reason of an increase in weight the heart in the recumbent posture 
sinks relatively lower, and hence the area of absolute dullness may 
a2:>pear smaller ; in the vertical position the heart descends, pushing 

* Dr. 0. Frantzel, "TJeber die Entstehung von Hypertrophie und Dilatation der Herz- 
ventrikcl durch Kriegsstrapezcn," Virchow's " Archiv," Band Ivli, S. 215. 
\ " The British Medical Journal," February 16, 1867. 



296 



DISEASES OF THE HEART. 



the diaphragm before it, and making the epigastrium more prominent. 
In texture, the substance of the heart is firmer than normal, and when 
divided has sharp edges which remain apart. In color, the tint is 
brighter and fresher looking than in the healthy state. Subsequently, 
if fatty change begins in isolated patches, the reddish-brown hue of 
the muscle will be marked by spots of a faintly yellowish or reddish- 
yellow color. It seems to be well established that the increase in the 
muscular tissue of the heart is a true hypertrophy, and not a hyper- 
plasia, that the existing elements are increased in size, but that no new 
elements are formed. Dilatation occurs chiefly in the auricles, which 
may be so stretched that the muscular elements undergo fatty degen- 
eration, are absorbed and disappear, leaving the endo- and pericardium 
in contact, or separated by some connective tissue only. The size to 
which the auricles may be expanded is enormous. The right ventricle 
may be much dilated and its walls thinned ; the orifices may be much 
enlarged, the trabeculse wasted, and the valves thinned. The left ven- 
tricle is rarely dilated merely, but the walls are also hypertrophied. 

Symptoms — Hypertrophy, — The signs and symptoms of cardiac 
disease are divisible into two groups —rational, physical. The rational 
signs are presumptive, and consist of the functional disturbances which 
indicate the probable seat of the disease ; the physical signs are de- 
rived from physical laws and methods, and are positive in their results. 
As respects the rational symptoms, the first point to be noted is, that 
those vessels receiving their blood-supply from an hypertrophied ven- 
tricle obtain more blood and with greater force than in the normal 
condition, and hence the tension in these vessels is higher ; whereas, 
the A^essels on the other side receive less blood with diminished force, 
and their tension is lower. When the left ventricle is hypertrophied, 
the tension is increased in the aortic system and diminished in the pul- 
monary. The opposite condition obtains when the right ventricle is 
enlarged, for then the pressure is greater relatively in the pulmonary 
system and less in the aortic. When both ventricles have undergone 
hypertrophy, the tension is increased in the aortic system and in the 
pulmonary artery. In consequence of the increased distributing power 
of the left ventricle, the blood-current is accelerated in the arterial 
system and communicating capillaries, and, as the pulmonary circuit 
has also a higher tension and greater celerity, the blood received from 
the great venous trunks is quickly disposed of, so that the tension falls 



























V 









Fig. 22.— Hypertrophy. 



in the venous radicles. The final effect of pure hypertrophy is an 
acceleration in the whole round of the circulation. The pulse is full, 
firm, and bounding. The ascent line of the sphygmographic trace is 



HYPERTROPHY AND DILATATION. 



297 



vertical and abrupt, but the summit is rounded and the descent oblique, 
unless there be regurgitation at the aortic orifice. The face is red and 
congested ; the nose bleeds easily ; the head feels full, and aches a 
good deal, esj^ecially when any strong muscular effort is made ; there 
are more or less tinnitus aurium and dizziness. When the arterial walls 
are weakened by atheromatous degeneration, cerebral haemorrhage 
may be a result of hypertrophy of the left ventricle ; but the way to 
rupture is prepared by gradual yielding of the arterial tunics, and 
the formation of minute aneurismal dilatations known as "miliary 
aneurisms." The strong beating in the superficial arteries is felt by 
the patient, and produces a disagreeable roaring and beating in the 
ears, especially when lying on the left side. The attacks of palpitation 
are frequent, but their severity is not in j)roportion to the extent of the 
hypertrophy, for the action may be very tumultuous when the enlarge- 
ment is slight, and vice versa. There are pretty constantly felt by the 
patient a sense of prsecordial anxiety, and, rarely, attacks of pain ex- 
tending to the shoulder and arm, similar to angina pectoris. A sense 
of fullness in the chest, of oppression, and sometimes embarrassed 
breathing are experienced, but the pulmonary symptoms may be due 
to congestion of the bronchial mucous membrane, supplied as it is by 
the bronchial arteries, and not from the pulmonary. When the hyper- 
trophy is confined to the right ventricle, no other lesion existing — an 
extremely rare condition — the symptoms present will be a sensation of 
fullness and oppression of the chest — possibly dyspnoea ; cedema and 
haemorrhage may occur, and the production of interstitial inflammation 
and possibly other diseases promoted. The foregoing signs of hyper- 
trophy are presumptive or rational ; the physical signs now to be con- 
sidered establish the seat and character of the lesion. On inspection 
there is to be observed a prominence of the chest, greatest at the junc- 
tion of the fourth and fifth ribs with the sternum. This has been denied; 
but, that it is often encountered in hypertrophy occurring in young 
subjects, the author's experience entitles him to affirm. AVhen hyper- 
trophy occurs later in life, the ribs having become rigid, no elevation 
of the chest-wall can be effected, how powerful soever may be the 
impulse of the heart. As in hypertrophy, the position of the heart is 
more horizontal and depressed to the left, on palpation., the apical im- 
pulse is felt near to the axillary line, and one, two, and possibly three 
intercostal spaces lower down, and it is stronger and more widely dif- 
fused. The force of the impulse is sufficient to raise the hand when 
placed on the cardiac region, or the head when applied in auscultation, 
and the whole left thorax may be felt lifted up and carried toward the 
left. This is entitled the heaving impulse, and is very characteristic 
of extreme hypertrophy. Instead of the impulse having a heaving 
character, sometimes it makes the impression of a sudden jar which is 
immediately arrested. In hypertrophy of the right ventricle the heav- 



298 



DISEASES OF THE HEART. 



ing impulse is felt at the end of the sternum, especially its right border, 
and in the epigastrium. In the third and fourth intercostal spaces to 
the right of the sternum, the impulsion of the hypertrophied auricles 
may sometimes be felt. On percussio?iy the area of prsecordial dullness 
can be demonstrated. The absolute or superficial dullness is that de- 
rived by percussion over that portion of the heart uncovered by the 
lung — a triangular space ; the relative or deep dullness is that obtained 
by strong percussion over that portion of the heart covered by the 
lung. The dull space extends from a point internal to the upper border 
of the second rib at its junction with the sternum, obliquely downward 
to the left to the apex-beat, thence transversely to the right border of 
the sternum. This is an irregularly triangular or ovoidal space which 
returns, on percussion, the forms of dullness mentioned above. The 
area of absolute dullness is increased by hypertrophy of the heart, if 
the patient is percussed when erect and inclined slightly forward. The 
relative dullness is increased more when the patient is recumbent, by 
the heart sinking backward. In hypertrophy of the left ventricle, the 
dullness is parallel to the long axis of the heart ; in hypertrophy of 
the right, the dullness is over the lower extremity of the sternum. 

When pure hypertro^^hy is the condition under examination, aics- 
cidtation furnishes no important information. The sounds of the heart 
are somewhat affected in their timbre. In hypertrophy of the left 
ventricle, the first or ventricular sound has a rather metallic quality, 
and the second sound is strongly " accentuated " ; in hyjDertrophy of 
the right, the same facts exist, but the sounds are less intense. At the 
apex, a peculiar metallic "click " is sometimes heard, and is doubtless 
due to the vibration in the chest-well, produced by a very strong im- 
pulse. It is much louder when the stomach is distended with gas. 

Dilatation. — When dilatation occurs in any of its forms, the propul- 
sive power of the heart is diminished ; less so, however, in active dila- 
tation. The result of this is a condition of ischaemia in one set of ves- 
sels, and of stasis in the other system. Thus, when the left ventricle 
is dilated, there is a lowering of tension in the aortic system, and an 
increase of pressure and abnormal fullness of the pulmonary ; when the 
right ventricle is dilated, there are diminution of tension, and ischjc- 
mia of the pulmonary artery, and elevation of pressure with stasis in 
the peripheral venous system. The ultimate effects of the disturbance 
in the vascular system are the same when one ventricle is dilated as if 
both were, for, taking as an examjDle the most common dilatation, that 
of the right side of the heart, the stasis in the peripheral veins extends 
to the capillaries, to the arteries, thence to the left side, and vice versa. 
When, however, dilatation of the right ventricle coincides with hyper- 
trophy of the left, the excess in power of the one compensates for the 
deficiency in the contractile energy of the other. The results of dila- 
tation of all the cavities are these : the vessels receiving blood from 



HYPERTROPHY AND DILATATION. 



299 



tlie heart — efferent vessels — are in a condition of isclisemia, or dimin- 
ished blood-supplj, while the vessels conveying the blood to the heart 
— afferent vessels — are constantly abnormally full, or in a condition of 
hypersemia and exaggerated tension. When the right heart is dilated, 
there are ischsemia of the pulmonary vessels, producing habitual dys- 
pnoea, insufficient haematosis or aeration of the blood, and stasis in the 
general venous system. The peripheral veins are turgid with blood, 
there is cyanosis from deficient aeration, and a constant hyperaemia 
of the liver, spleen, kidneys, and intestinal canal. Increase of pres- 
sui*e in the renal veins causes albuminuria; in the hepatic veins, jaun- 
dice and ascites ; in the veins of the extremities, oedema and general 
dropsy, and thrombosis. The rational symptoms of these functional 
disturbances are, palpitations of the heart ; frequency and irregu- 
larity of the pulse ; deficiency in the arterial blood-supply to the 
brain, and manifest in vertigo, ringing in the ears, attacks of faint- 
ness or actual syncope, etc. ; deficiency in the blood going to the 
lungs, and causing cough, dyspnoea, etc. The composition of the 
blood is impaired by the excess of carbonic acid ; the lessening of the 
oxidation processes diminishes the production of heat, and hence the 
general temperature is low ; the vessels themselves, the heart, and the 
tissues, undergo nutritive changes in consequence of insufficient energy 
in the process of tissue metamorphosis. A cachectic state, with low- 
ered vitality of the tissues, so that they ulcerate under the least irri- 
tation, is the necessary outcome of these changes. There is not only 
a lowered state cf the assimilative functions, but elimination is im- 
perfectly carried on, and excrementitious materials are retained in 
the blood — carbonic acid and urea — causing hallucinations, delirium, 
eclampsia, coma, etc. The ill results of these nutritive alterations are 
also exhibited in increased damage to the heart-muscle, and conse- 
quently an exaggeration of the mechanical effects of the dilatation. 
Inspection furnishes no information of value, excejot, when dilatation 
of the right cavities render the valves incompetent, a venous pulse 
will be visible in the neck. On palpation, the area of cardiac impul- 
sion is as wide as in hypertrophy, but the apical impulse is feeble, and 
may not be felt when the patient is recumbent. When there is hyper- 
trophy of the right heart to compensate for dilatation of the left cavi- 
ties, the apical impulse will be feeble, while the pulse of the right cavi- 
ties at the border of the lower sternum will be comparatively strong. 
On percussion the extent of dullness is made out as in hypertrophy. 
On auscultation, the sounds are feeble, as a rule ; on the other hand, 
they may have a more clear and resonant quality. A soft-blowing 
murmur sometimes takes the place of the first sound. This murmur 
is situated in the mitral and tricuspid areas, and is due to the insuf- 
ficiency of the valves to close the auriculo-ventricular orifices. 

Diagnosis. — Hypertrophy is to be distinguished from dilatation of 



300 



DISEASES OF THE HEART. 



the heart, from pericardial effusions, tumors of the mediastinum, etc. 
The force of the impulse, the accentuation of the second sound, and the 
state of the systemic circulation, enable the differentiation to be made 
from dilatation, and also from effusion ; besides, in the latter, the dull- 
ness has been preceded by a friction-sound, and, when the effusion 
comes on, the heart-sounds weaken and disappear. The seat of the 
dilatation is determined chiefly by the position of the dullness. Hyper- 
trophy and dilatation are differentiated from tumors in the mediasti- 
num, by the displacement of the heart occasioned by the latter, and by 
the persistence of the normal heart-sounds. The pressure of a tumor 
on the great vessels and important nerves introduces into the symp- 
tomatology of the case new symptoms quite foreign to either hyper- 
trophy or dilatation. From pleuritic effusion in the neighborhood, 
retained by adhesions — the so-called encapsulated — the dullness due to 
hypertrophy or dilatation may be diflicult to separate, but effusions 
displace the heart without altering the character of its impulse and its 
murmurs ; when the pleural effusions are unconfined, the ready dis- 
tinction consists in the change of the position of the patient, shifting 
the dullness. 

Course, Duration, and Termination.— The course of these affections 
is chronic, but hypertrophy continues much longer than dilatation. 
Hypertrophy, uncomplicated, exists unchanged for many years, and is 
important rather on account of the complications which may grow out 
of it than of itself, yet changes in the heart-substance and in the ves- 
sels must eventually result. Over-supply of blood to organs leads to 
nutritive alterations in them. Rupture of vessels may take place, but 
disease of the arterial tunics is necessary also ; hence the importance 
of hypertrophy of the heart as a factor in cerebral and in pulmonary 
haemorrhage. Dilatation of the cavities is much more rapid in its 
course and important in its results than hypertrophy, but simple and 
passive dilatations are more serious than the active form. The heart 
is much weaker, its tissues become diseased, and death may be sudden 
by paralysis or by rupture, or in attacks similar to angina pectoris. 
The stasis in the circulation, the pulmonary, hepatic, and renal trou- 
bles, and the general dropsy which result from dilatation, are the 
usual sequelae, and death ultimately occurs from the combined effect 
of these disturbances. 

Prognosis. — The prognosis is necessarily grave, but it should always 
be guarded. Simple hypertrophy may exist for years, without any 
apparent interference with function. In dilatation, the hope of any 
lengthened period of freedom from ill results can not be encouraged. 
When dropsy appears, it becomes a question of the physical endur- 
ance largely, for death can not, then, long be delayed. 

Treatment — Hypertroiohy. — When hypertrophy is compensatory or 
compensated, there is no need of therapeutical measures. It may, 



ENDOCARDITIS. 



301 



however, be necessary to combat the hypertrophy, or its results in 
the organism at large, if the force of the heart and the pressure in the 
vascular system are so great as to threaten serious consequences. The 
most direct method is the abstraction of blood, either by venesection 
or by leeches, and this is allowable in vigorous subjects. Purgatives 
lower the blood-pressure, especially the saline purgatives, which draw 
off by the intestinal mucous membrane more or less fluid. They are 
much less objectionable than bloodletting, are more easily handled, 
and are more permanent in results, Xext to saline purgatives in effi- 
ciency is the tincture of aconite-root. Tincture of veratrum viride is 
more powerful, but less easily managed, for its effects are quickly pro- 
duced and not easily confined within the prescribed limits. The action 
of the heart may be readily maintained by aconite at a uniform rate, 
which need not be lower than seventy beats of the pulse per minute. 
The abnormal fullness of the vascular system may also be lessened by 
reducing the gross amount of aliment taken in the twenty-four hours. 
This method will be all the more effective if the rate of waste is en- 
couraged by the use of potassa salts, which also increase the discharge 
of the products of waste by the kidneys. 

Tlie treatment of dilatation must pursue the opposite direction. 
The general nutrition must be maintained at the highest point, to pro- 
mote the nutrition of the cardiac muscle. A generous diet, moderate 
exercise in the open air, the inhalation of oxygen, are important agen- 
cies to accomplish the objects just mentioned. Bitters to increase the 
appetite and iron to improve the quality of the blood are strongly in- 
dicated. To tone up the heart and raise the tension of the vascular 
system, there is no remedy so efficient as digitalis. It should be given 
with quinia, which is also an excellent heart-tonic. The most remark- 
able effects attend the use of minute doses of morphia hypodermati- 
cally in these cases. When there is extreme dyspnoea, the heart very 
feeble, the fluid everywhere gaining, the effect of the injection is 
almost magical. It sometimes happens that the symptoms are too 
urgent to await the slow action of digitalis, or it may be the stomach 
will not tolerate the digitalis in any form, then the injection is most 
opportune — the patient is relieved by it — time is gained for the action 
of digitalis, or the stomach will bear it better. 

ENDOCARDITIS — INFLAMMATION OP THE ENDOCARDIUM- 
PLASTIC ENDOCARDITIS. 

Definitioil. — The endocardium is a delicate serous membrane, lining 
the cavities of the heart and forming its valves. The acute inflam- 
mation occurs in two distinct forms, which differ so widely as to 
require separate consideration : plastic, or simple exudative inflam- 
mation ; ulcerous, or diphtheritic inflammation. The plastic form is 



302 



DISEASES OF THE HEART, 



either acute or chronic, but these differ merely in degree and rate of 
progress. 

Causes. — Primary or idiopathic endocarditis, except in the ulcerous 
form, is extremely rare. Plastic endocarditis is usually a secondary 
affection : secondary to pleuritis, pneumonia, pericarditis, myocarditis, 
etc., but, very much more frequently, secondary to acute rheumatism. 
The relative frequency of endocardial inflammation in acute rheuma- 
tism is differently stated by different observers. According to some, 
one half, others one third, of the cases are complicated by endocarditis, 
but the real number is, no doubt, lower than one third. The source of 
error is the occurrence of a soft-blowing murmur in cases of rheuma- 
tism, due not to inflammation of the endocardium but to the condition 
of the blood. The more severe the type of rheumatic fever the greater 
the danger of cardiac complications, but there are numerous exceptions 
to this rule. The pericardial and endocardial inflammation may pre- 
cede the joint-troubles. 

Pathological Anatomy. — The initial lesion is hypergemia, which in- 
volves the sub-serous connective tissue as well as the membrane itself. 
The stasis in the vessels induces rupture of the capillaries, here and 
there, and minute extravasations are thus formed. Migration of white 
corpuscles, exudation of fibrinogenous and germinal matter, now takes 
place into the affected membrane, and the cells of the endothelium be- 
come cloudy, loosen, and undergo proliferation. The membrane, which 
in health is thin, transparent, and glistening, becomes, as a result of these 
changes, rough, opaque, and thickened. The roughness of the mem- 
brane is due, further, to the formation of lamellif orm or conical vegeta- 
tions, the product of the activity in cell proliferation at particular parts, 
or, according to Rindfleisch, they are composed of an homogeneous 
fibrinous exudation from the vessels. If the changes in the structure 
of the membrane do not go beyond this point, it is probable that com- 
plete restitution may occur. Proceeding from this point the inflam- 
mation may take the plastic or the ulcerous form. We are now con- 
cerned with the former only. The exudation on the auriculo-ventricu- 
lar valves (mitral) is found chiefly at the free border, where the ten- 
dons are inserted ; on the semi-lunar valves (aortic) on the lateral 
border where the segments come in contact, yet the corpora arantii 
may also be the seat of abundant exudation. The vegetations pro- 
jecting from the surface of the membrane entangle masses of fibrin 
whipped out of the blood, which may project from the valves, swing- 
ing to and fro like a polypoid excrescence. The chordae tendinae may 
be affected in a manner similar to the valves. Softened by the inflam- 
matory process, the chordae may give way, permitting a segment to 
become adherent to a neighboring one. Adhesion of the semi-lunar 
valves may occur at the side where they are in contact. The adhe- 
sions undergo organization, and thus the most serious changes are 



ENDOCARDITIS. 



303 



wrought in the structure and functions of the valves. Also, large 
masses of fibrin may be entangled in them, and they may be the cause 
of thrombotic deposits around them. When the inflammatory pro- 
cess passes to the chronic stage, characteristic changes take place in 
the exudation : it loses some part of its water, solidifies, and subse- 
quently contracts. The connective tissue undergoes hyperplasia, espe- 
cially the connective tissue of the borders of the valves, but the mem- 
brane, generally of the valves, may be affected by the same change. 
As a result of the tendency of the new material to contract, the valves 
become much deformed, thick, and inflexible, and, of course, their 
functions are correspondingly impaired. Calcareous changes occur in 
the deposits, and fatty degeneration also takes place. Patches of soft- 
ening may occur in the valves, the membrane yields, and pouches or 
aneurisms form, which ultimately give way, and thus a valve is per- 
forated. This process, occurring at various points, imparts to the 
valve a sieve-like appearance. Vegetations detached, or bits of ad- 
herent fibrin cast off, constitute emboli, which, entering the blood-cur- 
rent, will be deposited in distant parts — on the left side of the brain, 
in the kidneys, spleen, etc. The orifices of the valves undergo similar 
changes. The connective-tissue transformations take place, and hence 
rigidity, deformities, and contraction result. 

Symptoms. — When endocarditis is idiopathic, which is very rare, 
its onset is marked by the usual symptoms of an acute febrile or in- 
flammatory affection. There is a chill, followed by fever, a coated 
tongue, anorexia, nausea, sometimes vomiting, and general malaise. 
As it occurs in the course of another disease, the additional disturbance 
induced by it may altogether escape recognition, and it is only by per- 
sistent watchfulness, under such circumstances, that it is discovered. 
This is true of its onset in rheumatism, Bright's disease, the eruptive 
fevers, etc. On the other hand, the commencement of endocarditis 
may be manifest by very obvious signs. For example, if during the 
course of acute rheumatism endocarditis comes on, there will occur an 
increase in the temperature, the thermometer rising a degree or two, 
the pulse will become more rapid, and the general condition less favor- 
able, than before the complication arose. The fever does not pursue a 
special type, and the pulse exhibits no characteristic quality. The 
other rational symptoms are equally indefinite. There may or may 
not be some uneasiness in the region of the heart, some prsecordial 
oppression, and some palpitation. There may occur, also, increased 
impulsion of the heart, more rapid and tumultuous beating of the ca- 
rotids, headache, noises in the ears, some dyspnoea, etc. After a time 
the action of the heart becomes less energetic, the strength of the 
pulse declines, the function of hsematosis is impaired, and hence the 
functions generally, especially the cerebral, are less energetically per- 
formed. The physical signs are much more distinctive than the ra- 



304 



DISEASES OF THE HEART. 



tional ; the changes in the valves and at the orifices necessarily modify 
the character of the murmurs, or add new sounds. The period and 
position of the murmur are determined by the valve affected and by 
the time, in the cardiac revolution, when the blood-current passes the 
affected orifice. In mitral insufiiciency a hruit or murmur is audible 
with the first sound (systolic) at the apex, and with the second sound 
(diastolic), or after it (^presystolic), if there is obstruction at the mitral 
orifice. In aortic obstruction the murmur is audible with the first 
sound (systolic) at the base, and with the second sound (diastolic) if 
the aortic valves are insufiicient. If the lesions occur on the opposite 
or right side of the heart, which is very rare, the same rules obtain, but 
the position at which the sounds are heard is different. To hear the 
sounds at the right auriculo-ventricular orifice, the ear must be placed 
over the ensiform appendix, and, for the pulmonary valves, at the junc- 
tion of the third right rib with the sternum. Percussion affords but 
little information. If there be aortic obstruction, some distention of 
the heart is occasioned, which increases the area of dullness in the ver- 
tical direction ; if mitral obstruction, the right cavities will be some- 
what dilated and the dullness increased in the transverse direction. 
The facts may be formulated as follows : In acute endocarditis the 
same physical signs characteristic of chronic valvular diseases of the 
heart occur suddenly ; and, further, the sudden development of the 
symptoms of mitral insufiiciency is the most characteristic sign of 
acute endocarditis (Jaccoud). Obstruction or regurgitation a': the 
mitral orifice increases the pressure of the blood in the pulmonary ar- 
tery, and hence a physical sign of this condition is accentuation of the 
pulmonary second sound. More or less congestion of the lungs and sta- 
sis in the venous system are necessary consequences of mitral disease. 

Course, Duration, and Termination. — The course of acute plastic 
endocarditis is necessarily brief. The patient either partially recovers 
by the disease assuming the subacute and chronic phase, or he dies 
from the immediate consequences and complications. When the case 
passes from acute to chronic, the fever ceases, compensation takes place, 
by which the disorders of circulation are obviated for a time, yet the 
physical signs of valvular mischief continue. Death may result from 
a gradual weakening, terminating in paralysis of the heart, or heart- 
clot may form, or a cerebral embolism occur. Pericarditis, myocar- 
ditis, and pneumonia, may also intervene and take life. That a cure 
of actual lesions may happen is admitted, but the examples of such a 
fortunate termination are extremely infrequent. The duration of the 
acute attack is short ; of the subacute and chronic form, indefinite. 

Diagnosis. — The differentiation consists in the application of the 
physical signs. It should not be forgotten that a murmur exists of a 
soft-blowing character, not due to valvular lesion, and which disap- 
pears on the subsidence of the acute symptoms. 



ENDOCARDITIS. 



305 



Prognosis. — The acute form is not very dangerous to life, and hence 
a favorable prognosis may be expressed. As regards the ultimate re- 
sults of valvular lesions, the prognosis is grave. 

Treatment. — The character of the associated malady and the con- 
dition of the patient must enter largely into the consideration of reme- 
dies. As it is a fundamental principle to keep the suffering organ 
quiet, remedies capable of effecting this are very important — these 
are, ice and digitalis. An ice-bag should be applied to the prsecordial 
region, and a tablespoonful of infusion of digitalis given every four 
hours. Flying-blisters should be applied to the axillary region. In 
the incipiency, before much damage has been done, there can be no 
doubt of the great efficacy of the hypodermatic injection of morphia, 
or the internal administration of morphia and quinine — one quarter 
grain of morphia and ten grains of quinia every four hours until three 
or four doses are taken. When considerable exudation has occurred, 
besides the remedies to quiet the heart, ammonia should be given freely, 
with the view to exert a solvent action. The best form for adminis- 
tration is the carbonate (ten grains) in the solution of the acetate 
(half an ounce) every four hours, or half the quantity every two hours. 
If there be much depression in the progress of the case, quinia and 
digitalis should be prescribed in combination. 

ULCERATIVE ENDOCARDITIS— DIPHTHERITIC ENDOCARDITIS. 

Definition. — This is a peculiar form of disease, in which ulcerations 
and diphtheritic exudations, with colonies of micrococci, develop in 
the endocardium, followed by septic infection of the blood and mul- 
tiple embolisms. 

Causes. — A peculiar state or type of constitution seems necessary 
to develop this disease. It occurs during the' course of some cases of 
acute rheumatism, of puerperal fever, of diphtheria, etc., and now and 
then this process attacks the valves in cases of chronic plastic endo- 
carditis, the new material undergoing rapid and destructive ulceration. 
This disease makes its appearance between paberty and forty. A de- 
pressed condition of the vital forces, due to bad hygienic influences, 
seems to be very influential in determining the occurrence of this dis- 
ease in youths. The close analogy between the diphtheritic process 
and this ulcerous disease of the left heart and the frequent coincidence 
of the two affections render it highly probable that the diphtheritic 
poison is the chief if not the only factor in its causation. 

Pathological Anatomy. — The initial lesions are the same as those 
described under the head of plastic endocarditis. The lesions are 
chiefly on the left side of the heart, and attack by preference the 
anterior flap of the mitral and the semi-lunar valves of the aorta ; next 
the walls of the appendages to the left auricle ; and, lastly, the walls of 
22 



306 



DISEASES OF THE HEART. 



the ventricle. Occasionally the same morbid process occurs on the 
right side, and, in one reported case, on the tricuspid only,* and its 
chordae tendinaB, which were destroyed. After the initial changes 
already described, the nuclei of the connective tissue undergo rapid 
proliferation and form granulations of the surface ; fibrinous depos- 
its take place, and the whole forms a " felt-like " mass, intimately 
connected with the tissues beneath. A process of softening then 
begins in the interior of these masses ; they crumble and fall away, 
and leave a ragged, irregular ulcer, which is the seat of fresh fibrin- 
ous deposits. Perforation of the valve may ultimately take place, 
and the margins of the perforation are rough, ragged, and ulcer- 
ated ; and they are surrounded by granulations having the same struc- 
ture as those which have already ulcerated. A distinctive peculiarity 
of this process is the presence early in the course of formation of 
the granulations, and in the midst of the proliferating connective- 
tissue corpuscles, of a finely granular material, the particles having 
various shapes, strongly refractive of light, and resisting the action of 
acids and alkalies. These granules, as Yirchow was the first to point 
out, are micrococci, and the granular masses are colonies of micro- 
cocci. The losses of substance by thinning the valves lead to the for- 
mation of the so-called valvular aneurisms, and coagula forming in 
these are thrown off with patches of diseased tissue, when the aneurism 
gives way. Ulceration of the septum, induced in the same way, leads 
to communication between the cavities. The particles of ulcerating 
tissue, of fibrin and blood-clot, and the little masses of micrococci colo- 
nies thrown off into the blood-current, form multiple embolisms. Two 
results follow : either there is merely mechanical obstruction of vessels, 
or an infective process is set up the same as that of the original disease. 
The spleen, kidneys, and brain, are the organs in which these de- 
posits take place from the left side of the heart. When the disease is 
in the right side of the heart, the emboli are swept into the lungs. f As 
these organs contain the "terminal arteries" of Cohnheim, there will 
occur hgemorrhagic infarctions and ichorous suppuration. All tho 
organs of the body may, indeed, be the seat of abscesses from embolic 
deposits. The distribution of infective materials — specific micrococci 
— sets up a general infection of the blood. Wherever the micrococci 
are deposited they undergo rapid multiplication, and initiate the same 
morbid action as at the original source of infection. Numerous are 
the alterations occurring in various organs in ulcerative endocarditis. 
The spleen is very much enlarged, whether the seat of infarctions or 
not ; in the kidneys are abscess formations, and the afferent vessels 
are blocked with colonies of migrating micrococci ; in the brain there 

* T. Whipham, M. B., " Transactions of the Pathological Society," vol. xxii, p. 118. 
f C. J. Ebertb, Virchovv's " Archiv," Band Ivii, *' Ueber diphtherisclie Endocarditis." 



EXDOCARDITIS. 



307 



are extravasations, especially of the meninges ; in the lungs, abscesses 
from embo'i ; in the heart, myocarditis and pericarditis ; and in the 
small intestine, swelling of the patches of Peyer and solitary glands, 
and ulcerations which differ from those of typhoid, in that they are 
not confined to the lower extremity of the ilium, are not opposite the 
insertion of the mesentery, and are not limited to the glands."^ 

Symptoms. — Cases of ulcerative endocarditis differ much in their 
objective symptoms, but they may be referred to two types ; typhoid; 
pytemic. In both, the cardiac symptoms are quite masked by the pre- 
ponderating importance of the systemic state, and hence cases of pri- 
mary endocarditis are apt to be overlooked. When there is an attack 
of rheumatism going on, suspicion of cardiac mischief will of course be 
excited by the sudden occurrence of a violent chill which inaugurates 
both forms. In the typhoid form succeeding the chill there is con- 
siderable fever, the range of temperature being rather of the remittent 
type ; headache, vertigo, and extreme prostration, and sometimes a 
sense of prsecordial oppression, are then experienced ; the tongue is dry 
and brownish ; there are nausea and vomiting, and the bowels are con- 
stipated, or diarrhoea is present. The prostration gains rapidly, and by 
the fourth day a condition of depression is reached comparable to the 
second week of typhoid. The resemblance to typhoid is all the greater, 
since the abdomen is swollen and tympanitic and the spleen is enlarged. 
Delirium (irritation) soon comes on, to be replaced in a few days by 
stupor and coma (depression). A severe diarrhcea now succeeds to 
constipation, if that condition has existed before, and the perplexity 
of the case may be enhanced by rose-spots and petechias appearing on 
the abdomen. Presently, the patient lying in a comatose state, the 
stools and urine are passed involuntarily. The urine has a smoky ap- 
pearance, and contains more or less blood, and albumen is present. 
There is usually some bronchial catarrh, with cough and dyspncea — 
the latter, however, may be due to blocking of vessels and infarc- 
tions. On auscultation, a rather loud, systolic murmer is audible, usually 
with greatest intensity in the mitral area, or with the second sound 
in the aortic area. The X-^yciiriuc form begins with a chill, which is a 
decided rigor, followed by a high fever and sweating. The chills recur 
sometimes with the regularity of an intermittent fever, but usually 
very irregularly, as is proper to pyaemia. A condition of profound and 
increasing adynamia is soon developed. There is often a yellowish 
hue of the skin ; there may be jaundice, or there may occur petechial 
or htemorrhagic spots, or a roseola may make its appearance. During 
the maxima of the temperature curves the heat may attain to 105° 
Fahr. and the pulse to 140. Dyspnoea and accelerated breathing may 
indicate pulmonary infarctions and pneumonia ; enlargement of the 

* Rudolf Maier, Virchow's " Archiv,"' Band Ixii, " Ein Fall von primarer Endocar- 
ditis diphtheritica." 



308 



DISEASES OF THE HEART. 



spleen (infarctions of that organ) ; renal pains, albuminuria and haema- 
turia (infarctions of the kidneys) ; and apoplectic attacks and hemi- 
plegia (infarctions of the brain). Abscesses occur in the joints in a 
considerable proportion of cases. They are peculiar, in that they form 
with great rapidity ; are, when at rest, free from pain ; and are not 
manifest by swelling and changes in the form and appearance of the 
joint. In some cases there occurs an acute atrophy of the liver, with 
an intense icterus. Confusion of mind is observed with the onset of 
the symptoms, then an active delirium, followed in a short time by 
stupor, coma, and insensibility. Not all the cases conform to one or 
the other of these types ; some pursue an intermediate course ; others 
seem to be only aggravated cases of rheumatic fever. There may be 
no physical signs to warrant the opinion that endocarditis exists; there 
may be no marked affection of the joints — only vague pains in them, 
and in the muscles, yet there are maintained a high grade of tempera- 
ture and a rapid pulse, and the stomach continues much deranged. 

Course, Duration, and Termination. — The course of ulcerative endo- 
carditis is very rapid, the pysemic form being more quickly fatal. This 
form rarely continues longer than ten days, and many terminate within 
a week. On the other hand, the typhoid form may last three or four 
weeks, or even longer. Death may occur from paralysis of the heart, 
from heart-clot, from thrombus of the pulmonary artery, from pneu- 
monia, from cerebral embolisms, etc. 

Diagnosis. — A typical case of the typhoid or pyaemic form, occur- 
ring in the course of acute rheumatism, ought to be diagnosticated 
without difficulty. Generally the symptoms do not indicate the nature 
of the lesions. Probably ulcerative endocarditis is more frequently 
confounded with typhoid than any other malady. The differentiation 
can not be made from the symptoms, but from the history of the case. 
In typhoid there is slow development, and the grave symptoms do not 
come on until the first week is passed. The circumstances surrounding 
the individual and the occurrence of other cases in the neighborhood 
must be taken into account. 

Treatment. — Notwithstanding the apparently hopeless condition of 
the patient affected with ulcerative endocarditis, our efforts should be 
directed to the use of stimulants and support, and special remedies, as 
if there were a prospect of cure. As septic materials are circulating 
through the blood, the benzoate of ammonium, or salicylic acid, should 
be administered freely. To effect the solution of blood-clots and fibrin 
masses, we should keep the blood as highly alkalinized as possible by 
ammonium carbonate. Quinise and morphia are the appropriate reme- 
dies during the first few days; carbonate of ammonia and the benzo- 
ates, when the endocardium is disintegrating, and alcoholic stimulants 
and abundant food-supply throughout the whole duration of the case. 



VALVULAR LESIONS. 



309 



DISEASES OF THE VALVES AND OF THE ORIFICES.— VALVU^ 

LAR LESIONS. 

Definition. — Under the term " valvular disease " are included those 
alterations in the structure of the valves themselves, or of the orifices, 
which render the former incapable of performing their office in the 
closure of the latter. The lesions may be of two kinds — ohstructive, 
or regurgitant ; that is, the orifice may be so narrowed as to obstruct 
the passage of the blood, or the valves may be so damaged as to per- 
mit the blood to regurgitate. The narrowing of an orifice is termed 
stenosis ; the incompetence of a valve to close the orifice is termed 
insufficiency ; as aortic stenosis, mitral insufficiency, etc. There are 
four points at which these lesions may occur : on the left side, at the 
auriculo-ventricular orifice (mitral), at the aortic orifice (semi-lunar) ; 
on the right side, at the auriculo-ventricular orifice (tricuspid), at the 
pulmonary orifice (semi-lunar). 

Causes. — There seems to be no difference in the liability of the two 
sexes respectively to the occurrence of valvular diseases. Age exer- 
cises a very manifest influence in the production of aortic disease, by 
the development of atheromatous changes, while mitral lesions occur 
more frequently in youth. Still, the rule is not invariable. Aortic 
disease may be brought on in early life by overwork and strain of 
the heart, as was first pointed out by Da Costa. According to Bam- 
berger, the greatest frequency of mitral disease is from ten to thirty, 
and of aortic disease from thirty to fifty. The relative proportion of 
cases fatal from heart-diseases, in the deaths from all causes, is differ- 
ently stated by different observers, from two per cent, to twenty, but 
the lowest estimate is probably nearest the truth. The most impor- 
tant cause is, doubtless, rheumatic endocarditis, which affects all the 
valves, but greatly more frequently the mitral. The next in impor- 
tance as a factor is chronic endarteritis, or atheromatous degeneration, 
which usually affects the aortic orifice. Syphilis is also a cause, but 
the precise value of its influence in lighting up mischief in the valves 
is not known, and, as gummata are deposited in the walls of the heart, 
the lesions of the valves are usually secondary to myocarditis. Lea- 
red * reports a case supposed to he syphilitic, in which vegetations 
formed on the aortic valves, the patient having had recently a well- 
marked constitutional syphilis. 

Rational Signs and Symptoms of Valvular Defects. — When the nor- 
mal course of the circulation through the heart is disturbed by changes 
in the orifices and in the valves, certain consequences ensue to the 
heart itself, and to the organs in general. When stenosis exists at an 

* Dr. A. H. Leared, " Aortic Valve-Disease, apparently caused by Syphilis," " Path. 
Soc. Transactions," vol xix, p, 94. 



310 



DISEASES OF THE HEART, 



orifice, the amount of blood passing through is necessarily lessened, 
with the effect to cause ischsemia and lowered tension in front, and 
stasis and abnormally high tension behind. The same result follows 
if the contractions are feeble and the cavity dilated, for then the 
amount delivered in front is lessened, and accumulation takes place 
behind. Lesions of the aortic orifice, either obstructive or regurgi- 
tant, lead to dilatation of the left ventricle, to diminished blood-sup- 
ply, and lowered tension in the vessels of the aortic system, and to 
increased pressure and distention in the left auricle and pulmonary 
veins. Mitral lesions, either obstructive or regurgitant, cause abnor- 
mal fullness and distention of the left auricle and pulmonary system, 
and ischsemia and lowered tension in the left ventricle and aortic sys- 
tem. Again, lesions of the tricuspid orifice induce dilatation of the 
right auricle and increased pressure in the venae cavse, and ischsemia 
and lowered pressure in the right ventricle and pulmonary artery. 
Also, lesions of the pulmonary orifice bring about dilatation of the 
right ventricle, and elevated tension in the right auricle and vense 
cavse, and ischsemia and lowered tension in the pulmonary artery. Al- 
though obstruction and regurgitation of the aortic orifice affect first 
the aortic system, yet ultimately the dilatation of the left ventricle, 
and the changes in the auriculo- ventricular orifice will lead to incompe- 
tence in the mitral and general venous stasis. The same fact is true 
of mitral stenosis and regurgitation ; the arterial system does not 
receive its normal supply, and accumulation takes place in the pulmo- 
nary veins, and next in the right cavities. Obstruction and regurgita- 
tion on the side of the right heart lead to ischsemia in the pulmonary 
artery, then of the pulmonary veins, then of the left cavities, and 
finally of the aortic system, while stasis and high tension obtain in the 
venous system. The final result of valvular lesions on the circulatory 
system may be formulated as follows : All valvular lesions bring about, 
sooner or later, a state of the circulatory organs in which there are 
ischsemia and lowered tension in the aortic system and stasis and 
higher tension in the venous system. When compensation takes 
place, this formulated expression ceases to be applicable. By the 
term compensation is meant an adaptation of the organs of circulation 
to the new conditions imposed on them by the valvular lesions. Ste- 
nosis of an outlet is compensated by dilatation of the cavity and hy- 
pertrophy of the walls. Thus, in aortic stenosis, some dilatation of the 
cavity enables the heart to retain the excess in the quantity of the 
blood, and hypertrophy of the walls enables the left ventricle to de- 
liver the whole amount into the aorta. In this way the obstruction is 
compensated, so that the subjects of aortic stenosis are enabled to live 
in comparative comfort for many years. But the compensation may 
be easily ruptured or overcome. Any unusual work put on the heart, 
new obstacles introduced by disease in the lungs, or in the heart itself. 



VALVULAR LESIONS, 



311 



may disturb the compensatory relation, and the symptoms of valvular 
disease be resumed again with renewed force. 

The slowing of the current, which is a consequence of stenosis, of 
changes in the heart-muscle, and of stasis at some point in the circuit, 
has a disastrous effect by the formation of heart-clots. Coagula form 
in various situations : on the walls of the heart, entangled in the tra- 
becular, or in the auricles. These coagula are found more frequently 
on the right side, and hence hasmorrhagic infarctions in the lungs are 
results of valvular disease. A true infarction is possible in those 
organs only supplied with Cohnheim's terminal arteries. An embo- 
lus lodged in one of these stops the blood-current, and, the terminal 
artery having no anastomoses, there can be no collateral circulation ; 
but in the efferent vein, supplied through a communicating vein by 
an unobstructed artery, a recurrent movement of the blood takes 
place, flows on into the capillaries, then finally into the artery with a 
rhythmical movement. The result is, the wedge-shaped area sup- 
plied by the obstructed artery becomes deeply injected, and, vessels 
yielding under the increased pressure, a haemorrhage occurs. Thus 
is produced the pathological state called " hsemorrhagic infarction." 
If the infarction is large, or if several smaller ones unite, symptoms 
of disturbance in the pulmonary functions will be induced. There 
will be dyspnoea, mucous expectoration with more or less blood, chilli- 
ness, and the physical signs of consolidation — dullness on percussion 
and bronchial voice and breath sounds — the latter, however, recog- 
nized if the area of infarction be large and situated at or near the 
periphery. If the pleura is involved there may be pain and fever, 
but usually the temperature remains rather below than above the nor- 
mal. In some cases the infarction may be entirely healed, and nothing 
remain but a cicatrix ; in others, if the embolus be infective, a gan- 
grenous inflammation may take place ; in others, again, death ^may 
occur suddenly from blocking of a considerable vessel. 

The most usual pulmonary disturbance induced by valvular disease 
is stasis of the blood, which leads to catarrh of the bronchi, and is 
accompanied by cough, by mucous expectoration, mucous and sub-mu- 
cous rules, etc. Very important changes ensue in the intima of the ves- 
sels, and in the caliber of the capillaries ; the former undergoes an atro- 
phic change, the latter enlarge and become varicose, and, projecting 
into the alveoli, narrow the breathing-space, and thus cause dyspnoea. 
Under the increased pressure, vessels give way and haemorrhage occurs 
in the alveoli and intervening connective tissue ; and the blood un- 
dergoing the usual transformation, produces the so-called " red-brown 
induration." When the stasis has continued for a long time, and 
is extreme, the pulmonary tissue becomes oedematous. Difiiculty 
of breathing is a necessary result of these conditions. Besides this 
habitual difficulty of breathing, there are paroxysmal attacks of con- 



312 



DISEASES OF THE HEART. 



siderable severity, in which, without any increase in the number of 
respiratory movements, there is a sense of need of air, accompanied 
often by pain in the chest, in the shoulder, and extending down the 
arm. These attacks are more usual in cases of disease at the aortic 
ostium, due to atheromatous degeneration. In consequence of the 
slow circulation through the tissues, the blood loses more oxygen and 
takes up more carbonic acid ; in consequence of the interference with 
aeration caused by the pulmonary changes, the blood contains always 
more carbonic acid and less oxygen than is normal — hence cyanosis is a 
symptom in these cases. It exists, in varying degree, from a decided 
blueness of the whole surface to a faint blueness of the lips only. The 
condition of over-fullness of the venous system is further seen in the 
distended state of the superficial veins. The increased tension of the 
veins is an efficient factor in the production of cedema, the absorption 
of fluid is hindered from the same cause, and the state of the blood- 
serum favors outward rather than inward osmosis. The accumulation 
of fluid in the areolar tissue first occurs in the inferior extremities, and 
then gradually extends upward. Of the internal cavities, the perito- 
neum becomes earliest and most abundantly the seat of effusion, be- 
cause of the changes which take place in the liver in these cases of 
cardiac disease (see Congestion of the Liver). Next to the perito- 
neum, the left pleural cavity contains the most transudation ; next the 
sac of the pericardium. The severe pressure on the skin of the legs, 
which is also filled with serum, leads to inflammation of the skin ; it 
becomes tense, brawny, and congested, and finally ulcerates, forming 
a more or less extensive purplish excavation, exuding serum constantly. 
The ulcer or ulcers thus produced are liable to attacks of erysipelatous 
inflammation, to sloughing, and to deep-seated, burrowing suppuration. 

The condition of the blood which contributes to dropsical accumu- 
lation is produced by several factors. The loss of albumen and salts 
has the effect to prevent osmosis into the vessels of fluid in the tissues, 
which therefore accumulates, and the hepatic derangement and chronic 
gastric catarrh, which interfere very seriously with digestion and the 
absorption of its products. The appetite is either wanting or capri- 
cious ; food distresses the stomach ; the intestines are filled with gas, 
the result of the decomposition of certain kinds of food ; and diarrhoea, 
which nothing controls permanently, comes on toward the close. The 
continued hyperemia of the liver causes that appearance known as 
"nutmeg-liver," the connective tissue undergoes hyperplasia, and the 
organ, after a period of enlargement, contracts more or less. This 
state is often confounded with " cirrhosis," but the morbid process is 
different. The kidneys are affected by the variations in the tension 
of the vascular system. As a smaller quantity of blood than normal 
passes through the tufts of the glomeruli, the amount of urinary water 
decreases, and hence the urine is scanty in quantity, has a high spe- 



YALVrLAR LESIOXS. 



313 



cific gravity, deposits abundantly of urates, and finally becomes albu- 
minous as the tension increases in the venous system. The urine also 
contains much pigment, but there is rarely any blood present, and there 
are hyaline casts. The first effect of the persistent venous congestion 
is enlargement, due to over-production of connective tissue, but in the 
progress of the case atrophy occurs and the organs become reduced in 
size, very tough, and dark-purplish in color. These atrophic changes 
are due to the pressure of the contracting connective tissue and con- 
sequent wasting of the proper gland elements. During these altera- 
tions the tubular epithelium becomes granular and ultimately fatty, 
while the basement membrane also undergoes thickening. Infarctions 
sometimes occur in the kidney during the course of chronic cardiac 
disease ; they are due to obstruction in the branches of the renal 
artery by emboli ; they assume the characteristic wedge-shape, with 
the apex toward the hilus, and they undergo the same changes as in- 
farctions elsewhere. 

Very characteristic cerebral symptoms are also produced by car- 
diac valvular lesions, but they vary in character according to the valves 
affected. The disturbed state of the intra-cranial circulation thus occa- 
sioned doubtless leads to nutritive alterations in the walls of the cere- 
bral vessels. Furthermore, atheromatous change at the aortic orifice 
will be followed by similar changes in the intra-cranial arteries. Mil- 
iary aneurisms form when the walls of the small arteries undergo these 
changes. Rupture and consequent extravasation will then take place 
readily, because of the variations in tension of the blood-vessels. Em- 
bolism of the brain is exceedingly common in recent cases of endocar- 
ditis. Owing to the position of the left carotid and the left middle 
cerebral, it is pretty certain that an embolus dislodged from the valves 
of the left side of the heart will be deposited somewhere within the 
area of distribution of the left middle cerebral artery. Hence the fre- 
quent association of acute rheumatism, valvular disease of the heart, 
and right hemiplegia, with aphasia. Without causing organic lesions 
of any kind, very unpleasant and severe symptoms of intra-cranial 
disturbance are produced by valvular lesions, especially those of the 
aortic orifice. Xarrowing and obstruction, or regurgitation at the aorta, 
must necessarily produce anaemia of the brain, with the usual symp- 
toms of that condition, as sudden faintness, dizziness, tinnitus aurium, 
persistent headache, etc. Chorea has long been associated with endo- 
carditis. According to the well-known theory of Jackson, chorea is 
due to multiplex capillary embolisms of the corpus striatum, but this 
view is not generally accepted. In a large proportion — probably in 
one fourth — chorea is associated with rheumatic endocarditis, but the 
exact nature of the relation is not now understood. 



314 



DISEASES "OF THE HEART. 



AFFECTIONS OF THE AORTIC VALVES AND ORIFICE.— The 

alterations which occur in the aortic valves are very numerous, as re- 
spects the character of the resulting deformity. The segments may 
be adherent by their lateral planes, leaving a central opening through 
which only the little finger may protrude. A segment may be torn 
from its base in part or almost wholly.* This accident may result 
from a suppurating myocarditis, which so weakens the attachment 
of the valve that it gives way while in the performance of the ordi- 
nary functions. Such a degree of shortening and rigidity may ensue 
that the segments can not successfully approximate, or this change 
may take place in one or two segments. Besides rigidity and thick- 
ening, the valves may be deformed by ragged, dentated, and rough- 
ened margins. The margins of the segments may become thinned 
and slits form, presenting the appearance known as "fenestrated," 
or the so-called valvular aneurisms may occur, and, giving way, open- 
ings are made which render the valve incompetent. Atheromatous 
changes beginning in the aorta extend downward to the orifices, 
producing rigidity, narrowing, and deformity. Rough excrescences 
form and project into the ostium, and so small may it finally become 
that the smallest finger will barely pass through. The valves also 
become much altered by calcareous deposits ; they become rigid, 
roughened, and incompetent. As a result of the changes in the valves 
and orifices — stenosis and insufficiency — the left ventricle is kept 'too 
full and the cavity dilates. The septum between the ventricles is 
pushed over by the distention, encroaching on the right ventricular 
cavity ; the auriculo-ventricular orifice is stretched, and the segments 
of the mitral are drawn on and lengthened. The increased labor im- 
posed on the muscle of the left ventricle, to propel the blood into the 
aorta, induces an hypertrophy, and consequently the walls become 
thicker as the cavity enlarges, although the growth of the walls is not 
pari passu. The papillary muscles are stretched and flattened by the 
strain of the diastole, and are not hypertrophied. 

Symptoms of Stenosis, Rational and Physical. — The character of the 
pulse has high significance. The ostium being small and the ventricle 
hypertrophied, the pulse is small, slow, and hard. The sphygmographic 




Fig. 23. — Stenosis of Aortic Orifice. 



tracing exhibits these characters clearly. The ascensional line is rather 
oblique, the summit rounded, the abscissa low, the descending line ob- 
lique, and the interval long ; almost the opposite of the tracing in in- 
sufficiency. The supply of blood to the brain is insufiicient, and hence 

* Dr. Burney-Yeo, "Lancet," December 5, 1874, "Clinical Lectures on Rupture of the 
Aortic Valves." 



VALVULAR LESIONS. 315 

there are attacks of headache, vertigo, syncope, and the patient may- 
fall suddenly relaxed, with or without losing consciousness, or there 
may occur distinctly epileptiform seizures. The diminution in the 
quantity of blood passing to the brain may be the cause of serious nu- 
tritive derangements in the organ. The left ventricle undergoes dila- 
tation and hypertrophy, and, the mitral becoming incompetent, stasis 
takes place on the venous side. The lungs are kept abnormally full, 
haemoptysis and infarctions may occur, dyspnoea is paroxysmal, and 
there may be attacks similar to angina pectoris. In the progress of 
the case the heart becomes less capable of overcoming the resistance, 
and then, instead of a hard pulse, it becomes soft and weak. On pal- 
pation, the apical impulse has the position usual in hypertrophy, but 
it is much weaker than when there is insufficiency of the valves, and 
may, indeed, be scarcely perceptible. On percussion, the area of dull- 
ness is somewhat increased in the long axis, but little transversely, if 
at all. Auscultation furnishes a rasping, whistling, singing, or musical 
murmur, according to the character of the obstruction, and it is sys- 
tolic in time, audible with greatest intensity in the aortic area — at the 
junction of the right third costal cartilage with the sternum. It may 
be very loud and audible a short distance from the patient. If there 
be regurgitation also, a diastolic murmur will be produced. The dias- 
tolic normal sound will be weak because of the diminished elasticity 
and imperfect closure of the valve-segments. So long as compensation 
continues there may be no pronounced symptoms, and the heart may 
be equal to the ordinary duties required of it. When the compensation 
is ruptured by overwork of the heart, or by the occurrence of disease, 
then stasis will ensue in the venous system and dropsy will occur. In 
other cases the amount of obstacle is too great, and the compensation 
is imperfect ; then the disturbances due to the nature of the lesion 
will slowly develop. 

Symptoms of Insufficiency, Rational and Physical.— The pulse has a 




Fig. 24.— Pulse of Aortic Regurgitation, 



very different character from that in stenosis. The amplitude of the 
wave is great, the rise in the beat sudden, its declension rapid. It 
is known as the " water-hammer " pulse, or as the " Corrigan pulse," 
from Sir Dominic Corrigan, who described it. The sphygmographic 
tracing clearly indicates these qualities : the ascent is vertical, the ab- 



316 



DISEASES OF THE HEART. 



sciss lofty, the descent abrupt, and, if the case is purely one of re- 
gurgitation without other defect, the descent is not marked by 
the secondary wave produced by the closure of the valve and the 
recoil of the current. If there is no stenosis, so strongly is the blood 
propelled into the arteries that small vessels not before visible pul- 
sate distinctly. This condition of things produces the pulsation of 
the retinal vessels which may be recognized by the use of the ophthal- 
moscope. 

So long as this valvular defect is compensated by dilatation of the 
left ventricle, and hypertrophy of the walls — excentric hypertrophy — 
the objective and subjective symptoms are not very pronounced. There 
are usually a good deal of headache — the pain pulsating synchronously 
with the heart-beat — more or less dizziness, and pulsation, and tin- 
nitus aurium. When associated with atheromatous changes of the 
intra-cranial vessels, there is great danger of cerebral haemorrhage. 
When similar changes have occurred in the aorta and coronary 
artery, attacks of angina pectoris may take place. So long as the 
compensation continues unruptured, there will be no difficulty in 
breathing, no stasis in the venous system, no dropsy ; but, if from any 
cause the compensation becomes unequal, then there will ensue the or- 
dinary series of phenomena — dyspnoea, cough, enlargement of the liver, 
congestion of the kidneys, albuminuria, ascites and dropsy. As these 
cases may continue for years with the lesions compensated, the prog- 
nosis is more favorable than in any other form of organic cardiac dis- 
ease. As soon as the mitral becomes incompetent, dyspnoea begins, the 
initial symptom, usually, of the widespread disturbance which comes 
on in the fully developed cases. 

In aortic insufficiency, there are present the signs of hypertrophy : 
the area of dullness, especially the absolute dullness, is increased both 
in the vertical and transverse diameter, as has been already point- 
ed out in the discussion of hypertrophy of the heart. The murmur 
proper to aortic insufficiency is a churning, rushing, diastolic murmur, 
heard at the time and taking the place of the normal murmur, and 
audible at the aortic area — at the junction of the left third-rib cartilage 
with the sternum. Also, there is usually, independently of stenosis, a 
systolic murmur heard along the aorta and carotids, produced prob- 
ably by the movements of the column of blood in the dilated aorta, 
and by the vibration imparted to the walls of these vessels by the 
force of the impulsion. This is a rather soft and blowing murmur, 
not unlike the murmur of anoemia heard in the same situation. It has 
been shown, further, that a reduplicated sound — systolic and diastolic 
— is audible in the femoral artery without pressure when there is a 
marked degree of valvular insufficiency, and it may be developed when 
there is but little insufficiency, by pressure above and below the steth- 
oscope. This reduplicated sound should not be confounded with the 



YALVULAR LESIONS. 



317 



hruit which can be produced bj pressure of the stethoscope on any 
artery, and which is a single sound. 

Affections of the Mitral Valve and Orifice. — More frequently than 
at the aortic orifice, the changes in the valves are results of endocardi- 
tis — plastic or verrucose endocarditis. Atheroma and calcareous depo- 
sition are not such important factors as in lesions of the aortic orifice. 
Various changes occur in the segments of the mitral. One may be- 
come adherent to the ventricular wall ; the two segments may be 
united, the chordae tendinae of one segment breaking off ; there may 
be thickening and contraction of each ; the borders of the segments 
may be ragged, thickened by new tissue, and at the same time con- 
tracted so as to be quite too small to close the orifice ; there may be 
perforations of the valves by giving way of the so-called aneurisms or 
by ulcerations, and lastly the valves may unite, leaving a small central 
orifice. The margins of the ostium may also be thickened and nar- 
rowed by inflammatory changes ; there may be calcareous deposits, 
roughening and obstructing it, or the ostium may be enlarged by dila- 
tation of the cavity so that the valves, although normal, are unable to 
close it perfectly. Insufficiency of the mitral may occur alone, but 
usually stenosis and insufficiency occur together, and stenosis never, 
probably, without insufficiency. Whether insufficiency or stenosis, the 
result is, that the left ventricle is inadequately supplied with blood to 
distribute through the systemic vessels. The left auricle is over-dis- 
tended, and the tension in the pulmonary veins is high. The walls of 
the auricle are hj-pertrophied, and the endocardium is cloudy in con- 
sequence of nutritive changes. The intima of the pulmonary veins is 
altered by proliferation of its connective-tissue corpuscles, and by fatty 
degeneration. The pulmonary veins, the pulmonary artery, the right 
cavities, and the venae cavse, are kept over-distended and in abnor- 
mally high tension, because the blood is pumped back through, or can 
not pass through, the mitral orifice, and there is, therefore, ischaemia 
and low tension in the aortic system. 

Symptoms of Stenosis, Rational and Physical. — Having imusual 
work to do to overcome the obstruction in front, the left auricle be- 
comes hypertrophied. The left ventricle, having less volume of blood 
to discharge, diminishes in size somewhat, and the aorta also is re- 
duced in caliber, but this is not invariably the case, for there is often 
either a normal size of the ventricle or it actually becomes enlarged. 
For example, in a case of mitral stenosis narrated by Balfour, where the 
segments were "glued together by their margins," and "the opening 
was so extremely contracted as only to permit the point of the little 
finger," it is stated that the " left ventricle is slightly hypertrophied, 
not dilated." * The chief reason why, under a diminished volume of 



* "Diseases of the Heart," p. 136. 



318 



DISEASES OF THE HEART. 



blood, the left ventricle may undergo hypertrophy, is that the contrac- 
tile energy expended is necessarily increased, because of the obstacles 
in the circuit. The pulse is small, its tension low, and its rhythm 



Fig. 25.— Mitral Stenosis. 



irregular,* but the irregularity is not constantly present, and is a sign 
rather of rupture of the compensation. There are much cough, diffi- 
culty of breathing, bronchorrhoea, often bloody sputa, sometimes 
haemorrhage, red-brown induration and hgemorrhagic infarctions ; dila- 
tation of the right cavities ; general venous stasis, cyanosis ; enlarge- 
ment of the liver, ascites ; albuminous urine, and general dropsy. 
By enlargement and hypertrophy of the left auricle, by dilatation 
and hypertrophy of the right ventricle, and by the distention of the 
veins, the stenosis is for a brief period compensated. But the condi- 
tions present bring about a slow rupture of the compensation, without 
the introduction of new disturbances. The changes in the muscular 
tissue of the right heart, the degeneration of the walls of the dilated 
vessels, and the alterations produced by the congestion of the liver, 
intestinal canal and kidneys, suffice to bring on the group of disorders 
above mentioned, which belong to the mitral lesions. The rupture of 
the compensation is much facilitated by overwork of the heart, by 
pulmonary diseases, or by intercurrent febrile maladies. On inspec- 
tion, rather wide diffusion of the apical impulse is perceived, if there 
be an apical impulse strong enough for recognition. It is rather a 
widespread undulation than an impulse at a special point. It extends 
from within the mammillary line to the right border of the sternum 
and downward to the epigastrium. It may be absent. On palpation 
the apical impulse is found to be weak and unresisting, and a purring 
tremor is felt which may be diastolic or presystolic. If there be re- 
gurgitation, a purring tremor may also be felt synchronous with the 
systole. Both absolute and relative dullness are increased. 

The transverse dullness is more increased than the vertical, and 
extends to the right border of the sternum, even beyond, and over the 
xiphoid appendix. A murmur is audible in the mitral area, of a rather 
harsh, grating, or blowing character, and occurring with the diastole 
and extending on up to the systole. The murmur may be presystolic 
— that is, occurring just before and extending in to the systole, but 
there are differences of opinion in respect to the time of this murmur. 
The murmur is usually heard with greater distinctness when the patient 



* Balfour, " Diseases of the Heart," "Extreme Irregularity," p. 126. 



VALVULAR LESIONS. 



319 



sits upright leaning forward, or to the left. No murmur may be audi- 
ble in some cases under any circumstances. Then the rational signs 
of mitral lesions possess a high degree of significance, and deserve 
attentive study, and a failure to appreciate their value and overween- 
ing attention to the physical signs are fruitful sources of error, under 
these circumstances. While, when present, the murmurs are heard 
in the mitral area with the greatest distinctness, they are propagated 
toward the apex, and lost toward the base. In a few cases of steno- 
sis, another sign is to be heard over the apex, and at the pulmonary 
area, namely, reduplication of the second sound. Various explana- 
tions of this phenomenon have been offered, but the most probable 
is that the aortic and pulmonary valves do not close in the same 
instant of time, owing to the difference in tension of the aorta and 
pulmonary artery, the tension of the latter being relatively greater 
and therefore closing before the former. There is a sharp accentua- 
tion of the second sound in the pulmonary area, when the reduplication 
does not occur, owing to the high tension under which the valves are 
filled and closed. This characteristic of the second sound will disap- 
pear when the tension of the vessels declines from any cause or when 
the tricuspid becomes incompetent. 

Symptoms of Regurgitation or Insufficiency, Rational and Physical. — 
So long as the compensation continues, the patient may be compara- 
tively free from discomfort, but the existence of these circulatory de- 
rangements leads to pathological changes which effect a rupture of 
the compensation — e. g., the pulmonary disorders, which are thus 
brought about, the myocarditis which attacks the walls of the right 
ventricle, or an intercurrent disease of some kind. Prjecordial uneasi- 
ness, palpitation, cough, and dyspncea are the first symptoms experi- 
enced when the compensation is ruptured. The pulse becomes soft, 
small, rapid, and irregular, and while the sphygmographic trace ex- 
hibits these features there is nothing distinctive in its form. The 




Fig. 26.— Mitral Insufficiency. 



legs, presently, become osdematous, the cavity of the abdomen fills, 
the liver is disordered, the urine is loaded with albumen, and the pa- 
tient ultimately dies drowned in his own fluids. The physical signs 
are characteristic. As in insufiiciency of the mitral, there is more or 
less, usually considerable hypertrophy of the left ventricle, enlarge- 
ment of the cavity and thickening of the walls of the left auricle, hy- 
pertrophy and dilatation of the right ventricle ; the total result is that 
the heart is much enlarged, and lies lower and deeper than is the nor- 
mal condition. The area of dullness, absolute and relative, vertical 



320 



DISEASES OF THE HEART. 



and transverse, is enlarged, and the cardiac impulse diffused. On 
auscultation a systolic blowing murmur is audible in the mitral area, 
is propagated toward the apex, and may be most intense at the very 
extremity of the apex. This systolic himit may also, when loud and 
strong, be heard over the whole cardiac area, and posteriorly under the 
angle of the scapula ; it may take the place of the first sound, or be 
heard with it. Usually the murmur can be separated from the proper 
systolic sound, by very carefully raising the head from the stethoscope 
so that the ear but touches it. Sometimes the hruit is heard with the 
greatest intensity in the second intercostal space, external to the left 
border of the sternum, in the position of the appendix of the left auricle, 
and because of the regurgitating blood like " the fluid in veins produc- 
ing sonorous vibrations louder at the point of impingement than at that 
of origin " (Balfour). This, the explanation of Naunyn, is now gener- 
ally admitted. If there be obstruction as well as regurgitation at the 
mitral orifice, there will be, as already set forth, a presystolic murmur, 
extending up to the systole, or under some circumstances a diastolic 
murmur. In regurgitation, as in stenosis, there is marked accentuation 
of the pulmonary second sound, until, at least, dilatation of the cavity 
and incompetence of the tricuspid introduce new conditions. 

The diagnosis of mitral disease must rest on a careful survey of the 
rational and physical signs. Too strict attention to the physical and 
neglect of the rational signs are frequent sources of error. Exact 
localization of the murmurs to the areas to which they belong is most 
important. The history of the case necessarily enters into the ques- 
tion of its nature. When the indications afforded by the history of 
the case and the rational and physical signs coincide, any serious error 
is hardly possible. 

AFFECTIONS OF THE TRICUSPID VALVE AND ORIFICE.— 

Only once or twice, in one hundred cases of endocarditis, will the 
right auriculo-ventricular orifice be the seat of mischief, and then 
in association with similar changes on the other side of the heart, 
at the mitral orifice. Stenosis of the left auriculo-ventricular orifice 
and obstructive diseases of the lungs cause distention of the right 
ventricle and produce that kind of insufficiency which is known as 
relative insuflaciency. Regurgitation takes place through this orifice, 
because, being enlarged, the valves become unable to close it during 
the systole. Over-distention of the auricle and hypertrophy result 
from the regurgitation, and the tension rises in the venae cavae and 
venous system, while there are ischsemia and diminished tension in 
the aortic system. The right ventricle also undergoes hypertrophy, 
because it is filled under the increased pressure of the high tension 
in the veins and the hypertrophy of the auricle. Regurgitation is 
often due to changes in structure that are congenital, and stenosis 



VALVULAR LESIONS. 



321 



almost always. Yery rarely is stenosis produced by acute endo- 
carditis, and, when it does occur from this cause, the anatomical 
changes are precisely those which have been described as taking place 
on the other side. The results of stenosis are the same as those of 
regurgitation, and need not, therefore, be repeated ; but stenosis never 
exists alone, and is always associated with changes on the left side. 
The pulse is small, weak, but not otherwise altered. A very charac- 
teristic symptom is the occurrence of a pulsation in the jugular, 
synchronous with the cardiac movement. It ought not to be forgotten 
that waves are caused in the jugular by the respiratory movement — 
by the expiratory pressure. The true venous pulse does not extend 
beyond the bulb of the jugular, if the valves of the vein are intact, 
but by distention they become so, when the venous pulse is perceived 
along the whole extent of the vessel, extending even to the external 
jugular. It is synchronous with the contractions of the heart. The 
pulsation may be double, produced by the contraction of the auricle, 
and by the beating of the aorta, the vena cava superior lying in close 
proximity to that vessel. There is a feeble venous pulsation when there 
is regurgitation at the mitral orifice, a stronger one with coincident in- 
sufficiency of the tricuspid, and with the latter alone. That this pulsa- 
tion is produced by the lesions above mentioned, and is not an oscilla- 
tion in the blood-current caused in the various ways already described, 
is determined by merely compressing the vessel with the finger, when 
the following facts will be elicited : If the pulsation be due to the 
heart-movements (regurgitation), when the vein is compressed at its 
middle, it will continue below the point of compression and cease 
above ; if due to the beating of the carotid, it will continue above the 
point of compression, and cease below. If due to the respiratory 
movements, the pulsation will be synchronous with those movements ; 
if to the heart-movements, sychronous with them ; if respiratory, they 
will cease with the suspension of breathing; and, if cardiac, will continue. 
There is an equally characteristic venous pulse of the liver, which is 
felt immediately on the occurrence of the changes on the right side of 
the heart, because the hepatic veins are not provided with valves. 
The pulsation, synchronous with the cardiac movements, may be felt 
over the whole organ, or be confined to the right lobe. The venous 
pulsation in the neck may appear and disappear under the variations 
in the fullness of the right cavities and the force of the ventricular 
contractions. The hepatic pulsation is affected by effusions in the 
abdomen, as well as by the state of distention of the vena cava and 
the hypertrophy of the right ventricle. So long as the valves of the 
jugular remain intact, the increased tension under which their closure 
is effected causes a murmur, humming and clacking combined, which 
is audible in the bulb. The hypertrophy existing chiefly to the right, 
the area of impulse must be seen to the right, and is rather diffused. 
23 



322 



DISEASES OF THE HEART. 



Dullness on percussion, due to the enlarged right auricle, can be de- 
veloped to the right of the sternum from the second to the fourth 
rib, and the dullness due to the right ventricle, to the base of the 
sternum, to the xiphoid appendix, and to the central and right portion 
of the epigastric region. A pulsation produced by the right auricle 
can be seen and felt sometimes in the right, second intercostal space. 
On auscultation in the tricuspid area — the lower segment of the ster- 
num — we hear a blowing murmur, systolic in time, and most intense 
at the junction of the intercostal space between the fourth and fifth 
rib and the sternum ; sometimes, most intense over the xiphoid ap- 
pendix. This is the characteristic murmur, but there are associated 
with it the valvular mitral murmurs which almost always are present, 
and are audible with the greatest intensity at the mitral area and 
toward the apex. These are both systolic, presystolic, and diastolic, 
as has been pointed out. In the affections of the right auriculo-ventric- 
ular orifice, the pulmonary second sound is weak, because of the di- 
minished tension in the pulmonary artery, unless there is coincident 
obstruction or regurgitation at the mitral orifice, which causes an 
accentuation of the pulmonary second sound. The mechanical effect 
of the lesions on the right side is immediate, and compensation is 
possible to a very limited extent. Extreme venous stasis soon occurs, 
with the attendant symptoms of hepatic disturbance, ascites, albumi- 
nuria, general dropsy. The prognosis is therefore unfavorable. The 
diagnosis is difiicult because of the coexistent mitral lesions, but the 
lesions of the right auriculo-ventricular orifice are established by the 
determination of these physical signs: a well-marked, true venous 
pulsation of the neck ; a systolic murmur, audible with the greatest 
intensity at the junction of the intercostal space between the fourth 
and fifth rib with the right border of the sternum, and a weak, pul- 
monary second sound. 

AFFECTIONS OF THE PULMONARY VALVES AND ORIFICE.— 

These may be congenital or acquired. When acquired they are pro- 
duced by endocarditis, or are due to calcareous deposition and athe- 
romatous degeneration, but acquired changes are extremely rare. The 
results of stenosis and insufficiency are the same, and consist of dilata- 
tion of the cavity and hypertrophy, leading to insufficiency of the 
tricuspid. In insufficiency of the pulmonary valves the resulting con- 
ditions are the same as in the corresponding change at the aortic ori- 
fice. The pulmonary artery and its divisions undergo dilatation, the 
intima becomes the seat of the nutritive changes already described, 
and lobular pneumonia and hgemorrhagic infarctions occur in the 
lungs. The rational signs are dyspnoea, deficient aeration of the 
blood and cyanosis, distention of the superficial vessels, dropsy, pal- 
pitation of the heart, prsecordial oppression, sudden attacks of suffo- 



VALVULAR LESIONS. 



323 



cative feeling, with pra3cordial pain and intense anxiety, etc. The 
physical signs are those of enlargement of the right cavities, a loud 
diastolic murmur heard with great intensity at the left border of the 
sternum and the upper margin of the third rib, and propagated toward 
the middle of the sternum, opposite the fourth rib and downward, 
and is lost going toward and over the great vessels at the base. There 
may be also a systolic murmur. These symptoms only occur when 
the compensation is ruptured, for the hypertrophy of the ventricle 
walls and the dilatation of the cavity compensate very fully for the 
mischief done. 

Stenosis is a more important condition than insufficiency, but it is 
congenital stenosis with which we have to deal chiefly, the acquired 
condition being exceedingly rare. In congenital stenosis the changes 
consist in constriction of the pulmonary artery, unclosed foramen ovale, 
unclosed ductus Botalli, stricture at the ductus Botalli, with hypertro- 
phy of the right cavities. The importance of these congenital defects, 
besides the damage to the heart, consists in the frequent association of 
these anatomical anomalies with tuberculosis of the lungs. The right 
ventricle enlarges to a remarkable extent, the walls attaining in thick- 
ness to the dimensions almost of the left. The result is, there are pres- 
ent the physical signs of hypertrophy of the right ventricle — an in- 
creased area of cardiac dullness to the right ; a blowing, systolic mur- 
mur, audible in the pulmonary area, and propagated not toward the 
base and great vessels, but somewhat to the left and a little down- 
ward, the point of greatest intensity being the junction of the third 
rib, upper border, with the left border of the sternum ; weak or inau- 
dible second sound. The rational symptoms correspond to the ana- 
tomical conditions. The compensation effected by dilatation and hy- 
pertrophy of the right ventricle suffices to maintain a condition of 
comparative comfort, but unusual physical exercise, obstructive pul- 
monary diseases, and other causes bring about a rupture of the com- 
pensation, when there ensue difficulty of breathing, cough, cyanosis 
that may be very intense, but general dropsy and albuminuria occur 
only when the right ventricular wall weakens by myocarditis. 

The duration of these cases of congenital defects in the structure 
of the heart varies with the degree of deformity and the circumstances 
in life. The compensation may be so perfect that the heart is equal to 
the needs of a quiet existence, and comparative comfort may be en- 
joyed by youths who possess even a considerable degree of cyanosis. 
But the degree of cyanosis is usually a measure of the success of the 
efforts at compensation. The subjects of congenital pulmonary stenosis 
are otherwise imperfect in organization — they are comparatively weak, 
develop slowly, have soft, flabby muscles, bones do not unite, and the 
nutrition continues poor. Beside the cyanosis, which is usually most 
strongly marked in the extremities, they have cold hands and feet, and 
possess but little endurance of cold, are subject to asthmatic attacks, 



324 



DISEASES OF THE HEART. 



to giddiness and vertigo, to epileptoid attacks, etc. The duration of 
life in these congenital cases varies from a few months to twenty or 
thirty years. 

Treatment. — In a clinical lecture published a few years ago * which 
is marked by that clinical acumen and power of accurate expression 
characteristic of the author, Flint emphasizes the necessity for caution 
in the expression of opinion to the subjects of cardiac mischief ; the 
importance of recognizing the fact that some murmurs have no patho- 
logical nor clinical significance ; the good results obtained from the 
treatment of associated morbid states in cases of undoubted valvular 
disease ; and, finally, the striking relief derived from the timely use of 
"digitalis and active hydragogue purgation repeated from time to 
time." Any one having clinical experience will fully and entirely 
agree with the distinguished professor in these observations. When 
the mischief done to the heart is recent, and the newly formed con- 
nective tissue is contracting, it is highly important, as Fothergill f has 
pointed out, to give the heart " physiological rest," to enable the dam- 
age to the valves to be repaired as completely as can be effected. The 
rest is best secured by maintaining the recumbent posture much of the 
time during the period of convalescence, by the careful administration 
of veratrum virido, to keep the revolutions of the heart at about fifty 
to sixty per minute, and by iron and suitable diet to improve the qual- 
ity of the blood, or by the use of nitro-glycerin to lessen the work of 
the heart in overcoming the peripheral resistance, and to improve the 
nutrition of the organ. When compensation is effected and the heart 
is equal to the obstacles, no medicinal treatment is necessary. Every 
effort must be directed to the maintenance of the compensation, by 
quietude of mind and body, and by avoidance of all causes of diseases. 
Active exercise, climbing mountains, running up stairways, lifting, and 
every kind of physical exertion involving heart-strain, must be avoided ; 
nevertheless, daily open-air exercise and exposure to sunshine are ne- 
cessary to maintain health at the proper standard — for, if the blood is 
impoverished by an in-door life and the want of appetite and imper- 
fect sleep, which are necessary results, the rupture of the compensation 
must then take place. In the natural course of events in valvular af- 
fections, the nutritive alterations which occur in the tunics of the ves- 
sels and in the heart-muscles ultimately effect a rupture of the com- 
pensation. Anaemia not only hastens the pathological processes taking 
place in the vessels and in the heart, but it actually inaugurates similar 
changes. It is, therefore, a measure of the highest importance to keep 
the appetite, digestion, and blood-making process in the most efficient 
state. Moderate exercise in the open air daily must be enjoined in 
these cases, while fatigue and strong exertion of any kind are avoided. 

* The " Medical News and Abstract," January Y, 1880. 
f " Diseases of the Heart," second edition. 



VALVULAR LESIONS. 



325 



When the heart is behaving badly in consequence of the anaemic con- 
dition, the organ is relieved by attention to the nutrition. Unless, 
therefore, under such circumstances there is plain need of digitalis, it 
should be avoided, for this agent disturbs the stomach and interferes 
with digestion. When, in women especially, the compensation is not 
ruptured, but great distress is experienced from anaemia or the chlo- 
rotic state, the indications clearly are not to treat the heart, but those 
nutritive disturbances on which the functional troubles depend. When 
such subjects are not relieved by stomachic tonics, iron, and a generous 
diet, the system of rest, forced feeding, massage, and muscular faradi- 
zation proposed by Weir Mitchell may be resorted to with advantage. 
Besides the measures necessary to prevent or overcome anaemia, the 
dietetic management requires the patient with compensated valve- 
mischief to avoid such cardiac stimulants as tea, coffee, tobacco, and 
alcohol in any form, except a little wine allowed at dinner provided it 
improves digestion. The choice of a suitable chalybeate can be made 
from a long list of preparations. It is a rule that combinations of iron 
with a mineral acid are more effective and often better borne than 
the milder and supposed more easily assimilated citrates, tartrates, and 
carbonates. German therapeutists much prescribe the ethereal acetated 
tincture of their pharmacopoeia. The tinctura ferri chloridi is, proba- 
bly, the most generally useful and efficient of the officinal preparations. 
It should be given always well diluted with water after meals, and 
should be taken through a glass tube or a straw. An excellent sto- 
machic tonic is tincture of nux vomica — ten drops to twenty — ter in die 
and before meals, or the milder tinctures of colomba or gentian may 
be preferred, A combination of great value in these cases is the elixir 
of the phosphates of iron, quinia, and strychnia (Aitken). The nutri- 
tion in cases of compensated valvular lesions often fails slowly, from 
the gradual congestion of the liver and of the intestinal mucous mem- 
brane. The digestion is slow and insufficient, the appetite fails, and 
the absorption of aliment is seriously intefered with by the hyperaemia 
and distention of the vessels. Timely recognition of this state and 
the use of appropriate means will prevent serious trouble. Excellent 
remedies are iridin and euonymin ; they are stomachic tonics, and, in 
sufficient quantity, powerfully stimulate the hepatic functions and de- 
plete the portal system. The treatment should be commenced by free 
action of the intestines procured by these agents or corresponding ones. 
Then stomachic tonics, chalybeates, and digestives, as pepsin and lac- 
topeptine, are indicated. The kidneys should be kept active, and this 
is best accomplished by the simultaneous but not conjoint use of a 
chalybeate and a diuretic, as tincture of iron and solution of bitartrate 
of potassa — the iron to be taken after meals, and the potassa solution 
to be drunk freely between meals. An excellent method of managing 
these cases, when a rupture of the compensation is threatened, is to 
give two or three times a week some efficient doses of iridin or euony- 



326 



DISEASES OF THE HEART. 



min, and to prescribe iron, quinine, and digitalis in pill-form — a half 
grain of f errum redactum, three grains of qiiinia, and a grain of digi- 
talis in a ]3ill three times a day. If the stomach is doing fairly good 
AYork, the best results may be expected from this combination. The 
practitioner is usually consulted when the failure of the heart, dyspnoea, 
cough, anaemia, albuminuria, and beginning dropsy, announce the rup- 
ture of the compensation. The principles of treatment differ some- 
what, according to the seat and character of the lesion and the condi- 
tion of the system. As the ultimate effect of all cases of valvular dis- 
ease of the heart is to cause ischaemia of the arterial system and stasis 
of the venous, a general method of therapy may be first developed and 
the special indications pointed out subsequently. The remedy which, 
above all others, opposes the condition of the vascular system in val- 
vular disease of the heart is digitalis. In prescribing this agent there 
are several points to be carefully considered. Is the digitalis of two 
years' growth ? Is it English or German ? Is it wild or cultivated ? 
The second-year plant contains more of the active principle ; the pro- 
duction of this continent seems inferior to that of English or German 
sources ; the wild digitalis is more active than the domesticated. For 
the effect on the circulation and on the kidneys, the officinal infusion is 
to be preferred to the other preparations, but the infusion is only ser- 
viceable when it is made from the proper digitalis. It must be given in 
sufficient quantity to produce its physiological effects — to diminish the 
number but increase the force of the pulsations ; to raise the tension 
of the vessels ; to increase the urinary discharge. The higher the 
tension at the periphery, the more decided the recoil, and consequently 
the better filled is the coronary artery, which includes a more active 
and healthy state of nutrition of the cardiac muscle. The higher ten- 
sion of the vessel means an arrest of the outflow of the serum and more 
active absorption. When the compensation is ruptured, the digestive 
organs suffer and the blood-making is inefficient. Excretion by the 
liver is hindered, and the waste of albumen through the kidneys lessens 
rapidly the amount of this important constituent in the blood. The 
poverty of the blood reacts, again, on the circulation through the heart. 
When, therefore, the necessity for digitalis arises, the demand for iron 
and bitter tonics (quinia) must be heeded also. Experience has abun- 
dantly demonstrated that the effects of digitalis are more decided and 
more lasting when iron and quinia are given at the same time. A 
tablespoonful of the officinal infusion three times a day until the char- 
acteristic effects are produced, and then twice a day, is the amount 
usually required and that can be borne. As its action is slow, frequent 
repetition of the dose may cause serious symptoms. If large doses are 
taken, and if the pulse is much reduced, the patient should maintain 
a fixed position — what position soever it may be — and not change it 
suddenly. Especially should he not rise suddenly from the recumbent 
posture, for under these circumstances the pulse becomes rapid and 



VALVULAR LESIONS. 



327 



feeble and the surface cyanosed. When headache, dizziness, disturb- 
ances of vision, vibration of external objects, and anxiety are produced, 
the dose must be at once reduced or discontinued. It should also not 
be forgotten that digitalis continued in large doses affects the motor 
power of the heart ultimately, by exhausting the irritability of the 
ganglia, when the action becomes rapid, weak, and irregular. It is 
good practice, during the long-continued use of digitalis, to suspend it 
for a few days at a time. If it can not be borne, cimicifuga may be 
substituted — a half to a drachoi of the fluid extract three times a day. 
Sufficient attention has not been given to the utility of cimicifuga as a 
cardiac tonic and substitute for digitalis. Caffeine and convallaria are 
more active agents, which more nearly approach digitalis in power, and 
may be substituted for the latter when its effects on the stomach re- 
quire it to be discontinued. In antagonism to some of the actions of 
digitalis, and as a means of lessening the work of the heart, we can not 
speak too highly of nitro-glycerin. Of the mineral tonics, no one is so 
serviceable as the acetate of lead. When there is much oppression of 
breathing, the patient unable to lie down, and becoming exhausted from 
loss of sleep, no remedy is so valuable as morphine hypodermatical- 
ly. It affords surprising relief to the distressing symptoms, improves 
remarkably the driving power of the heart, causes free diaphoresis, and 
gives time for the action of the other remedies. From the yV i 
a grain of morphine, according to the character and susceptibility of 
the patient, should be given. Next to the remedies for the heart, in 
importance, are the hydragogue cathartics. The greatest relief is 
afforded by draining off fluid from the intestinal mucous membrane. 
Euonymin and iridin have already been mentioned, but more powerful 
remedies are necessary when there is general dropsy. One of the most 
useful and efficient of these is the compound jalap powder. As it is 
important not to interfere with the digestion, this remedy should be 
administered in the early morning. If not sufficiently active, podo- 
phyllin may be added, or, this failing, elaterium may be substituted. 
Free transpiration by the skin should be maintained. This is best 
effected by the vapor-bath. The mistake must not be made of attempt- 
ing to act on the skin and kidneys at the same time. When digitalis 
is being taken, and bitartrate of potassa or other diuretics, the skin 
must not be excited at the same time ; on the other hand, free purga- 
tion assists the action of diuretics. When digitalis can not be borne 
by the stomach, it may act quite efficiently by external application to 
the abdomen or back : some leaves inclosed in a muslin bag are steeped 
in warm water, and kept applied for several hours. When the vapor- 
bath can not be used, a good substitute is a warm wet-pack covered 
with blankets. Remarkable benefit has been obtained from the treat- 
ment by compressed air, and by the inhalation of oxygen. The com- 
pressed-air treatment diminishes the tension in the venous, and elevates 
it in the aortic system, and also gives relief by contributing to the 



328 



DISEASES OF THE HEART. 



oxygenation of the blood. Oxygen merely acts in the latter mode, and 
often affords great comfort when there are paroxysmal attacks of dysp- 
ncea. There are some limitations to the use of digitalis in ruptured 
compensation with its direful results. It can not be borne at all by 
some subjects. It is contraindicated in aortic stenosis, and maybe dan- 
gerous in large doses. When there is mitral insufficiency, as well as 
aortic stenosis, digitalis may be given, but only in small doses, with a 
view to its diuretic action. Again, digitalis is of doubtful utility if not 
positively contraindicated in fatty heart, and consequently in cases of 
dropsy from dilatation and insufficiency due to fatty degeneration. 

HEART-CLOTS. 

Definition. — By the term heart-clot is meant a mass of fibrin or 
of coagulated blood found in one or more of the cavities of the heart. 
They are divisible into three varieties : First, translucent masses of 
fibrin, soft, yellowish, and full of serum, loosely attached to the 
chordae tendinse, trabecula3, or other projecting parts ; second, large, 
loose, black coagula occupying the right ventricle or auricle, and ex- 
tending into the pulmonary artery or venae cavse ; third, coagula of 
variable size, attached to projecting parts, found in all cavities, but 
chiefly in the left ventricle, and consisting of coagula containing a 
puriform-looking fluid in their interior. The first variety is not 
pathological, is formed during the death-agony or after death, and 
is found in the subjects of chronic wasting disease. The second va- 
riety may or may not be pathological, and stand in a genetic relation 
to the suspension of the cardiac movements. The third variety is 
always pathological. 

Causes. — The occurrence of these clots is not affected by sex, but 
they are more frequent at the middle period than at the extremes of 
life (Bristowe*). There are two leading factors in their causation — 
a condition of the blood ; disease of the heart itself. In many diseases 
the fibrin ogenous substance seems to be greatly increased, and thus a 
state of ready coagulability is induced. If, under these circumstances, 
the coagulation of the blood is favored by a slow and feeble action of 
the heart, a slight cause suffices to determine it. The actual deter- 
mining cause is disease of the heart itself, roughness of some project- 
ing part, or fibrinous concretion deposited on such rough surface. f 

Pathological Anatomy. — Clots are found in all the cavities of the 
heart, but most frequently in the left ventricle and least frequently in 
the left auricle (Bristowe). They form in by-places, and are entangled 
in the rough surfaces and inequalities. The appearance of the clots 
differs according to the circumstances of their formation. Leaving 

* " Pathological Society's Transactions," vol. xiv, p. Vl. 
f Ibid., cases by Dr. J. W. Ogle. 



HEART-CLOTS. 



329 



out of consideration the masses of fibrin, whicli liave no pathological 
import, the two other varieties differ in consequence of the changes 
wrought by age. The second variety mentioned above consists of a 
large, black, rather loose venous coagulum, which fills one or the other 
cavity of the right side and projects into the annexed vessel, which 
may be completely filled by it. Such a clot, we may suppose, is some- 
times the cause of death after post -par turn haemorrhage, or such as Sir 
Joseph Fayrer describes * as forming and causing sudden death after 
surgical operations. After profuse haemorrhage of this kind, the pro- 
pelling power of the right ventricle is so feeble that coagulation may 
readily ensue. The shock of a surgical operation may induce such 
slowness and weakness as a severe hjemorrhage, and result in the same 
accident. In the third variety the clot has undergone transformations 
due to age. It is firm, tough, grayish, yellowish, and brownish in 
strata, or variously intermingled, and attached to tbe columnae carneoe, 
chordae tendinse, or other parts. It usually contains in the interior, 
in a pseudo-cyst, a quantity of thick fluid having a " grumous " or 
*'puriform" appearance, and consisting of the fibrin, red and white 
corpuscles, undergoing the transformation usual to blood under these 
circumstances, f These clots are in position for a long time, often. 
Rarely are they found in a sound heart, and usually the changes of 
endocarditis have taken place, the coagulation of the blood being in- 
duced by roughening and exudation of the membrane. 

Symptoms. — Nothing can be more indefinite than the symptoma- 
tology of heart-clots. Nevertheless, we may make an attempt to define, 
from recorded cases and from observation, the character of the dis- 
turbances of function caused by them. There are two distinct groups 
of symptoms belonging to the two forms of clot. Aher p)Ost-partum 
haemorrhage, or after a surgical operation, or during the course of 
some septic disease, there suddenly comes on an extreme oppression of 
breathing, wild restlessness, beating about the bed and crying out for 
air, deep cyanosis, a fluttering heart without pulse at the wrists, which 
stops in a few minutes ; the patient falls back, the agitation ceases, 
but then a general convulsion may occur, and all is over, or death 
occurs quietly without any convulsive movement. In the other variety 
the symptoms develop more slowly, and may extend over several weeks. 
The earliest symptoms are irregularity in the heart-movements, indis- 
tinctness of the murmurs, difficulty of breathing, anxiety, oppression, 
cyanosis. The action of the heart becomes more and more feeble, the 
sounds run into each other and are dull and confused, the diificulty of 
breathing continues, moist relies appear all over the chest from oedema 

^ *' The Medical Times and Gazette," vol. i, ISTS, p. 58; also " rathological Society's 
Transactions," vol. xxvii, p. 70. 

f Cases by Dr. J. W. Ogle, " Pathological Society's Transactions," vol. xiv, p. 65, 
et seq. 



330 



DISEASES OF THE HEART. 



of the lungs ; the cyanosis deepens ; dropsy comes on ; stupor passing 
into unconsciousness, and convulsions end the scene. 

In most of the cases recorded by Ogle, the urine was albuminous ; 
there were lesions of the lungs, and effusion into the thoracic cavity. 
While the recorded symptoms are closely similar to the account given 
above, the state of the heart as to rhythm and the character of the 
sounds differ among themselves, and agree in part only with the 
above description. The duration of these cases ranged from a few 
days to six weeks, and the symptoms during that time seemed to de- 
pend on the presence of the clot found post mortem. 

Treatment. — Notwithstanding the uncertainty which must attend 
the diagnosis in these cases, which at its best must be a fortunate 
guess, some details of treatment are necessary. The treatment by 
frequent small doses of ammonium carbonate offers the best prospect 
of relief. In the cases which occur suddenly, and immediately extin- 
guish life, the intra-venous injection of ammonia should be practiced. 
This method consists in the injection into any vein — in this case, the 
jugular — of one part of aqua ammoniae to two parts of water, by an hy- 
podermic syringe. Of course, precautions must be taken to avoid the 
introduction of air or any foreign body. It has been abundantly 
demonstrated that this intra-venous injection of ammonia is entirely 
safe. In the less acute cases, there is a small prospect of success from 
the persistent use of the ammonia. The action of the heart must be 
maintained by the judicious use of digitalis and alcoholic stimulants. 

PALPITATION OF THE HEART. 

Definition. — By the term palpitation of the heart is meant a func- 
tional disturbance of the organ, characterized by increased rapidity of 
movement, with more or less irregularity of rhythm. 

Causes. — The heart possesses a power of independent motion ; but 
as this motor apparatus is not sufficient to keep up the action of the 
organ, it receives accessions of force from the great centers. To 
maintain the movement at a uniform rate, there is a regulator ap^oara- 
tus, designed to prevent overaction, or " to inhibit." Besides this mech- 
anism for evolving force, and applying it so as to produce uniform 
results, the action is affected by the state of the vessels, by the den- 
sity of the blood, by the movements of the respiratory organs, by the 
activity of the organic functions in general, and by the functions of ani- 
mal life. Accordingly, to maintain the action of the heart, there are — 
1. A motor apparatus — rhythmically discharging motor ganglia — situ- 
ated in the substance of the heart. 2. Exsitors of activity, branches from 
the cervical sympathetic, and also from the spinal cord, irritation of 
which increases the movements of the heart. To regulate the move- 
ments of the heart, there arc — 1. The pneumogastric, irritation of which 



PALPITATION OF THE HEART. 



331 



may arrest the heart in the diastole. 2. The depressor nerve of Lud- 
wig, which acts by dilating the blood-vessels. The fibers of the sym- 
pathetic, dilator, and constrictor, alfect the work of the heart by 
increasing or lessening the tension at the periphery. When the pe- 
ripheral vessels are dilated, the work to be done by the heart lessens, 
and hence the contractions are less numerous and forcible, and vice 
versa. 

The mechanism by which the action of the heart is kept at a uni- 
form rate may be disturbed by a variety of causes : by muscular 
exercise ; breathing rarefied air, as in the ascent of mountains ; by 
mechanical interference with the movements of the organ, as thoracic 
effusions, tumors of the mediastinum, flatulent distention of the stom- 
ach, atheroma of the arterial system generally, etc. Moral and emo- 
tional causes, as grief, hope, anxiety, fear, excessive mental effort, etc., 
increase the action of the heart. Various reflex troubles have the 
same effect — as affections of the nervous system, reacting on the ner- 
vous apparatus of the heart — such as uterine disease, gastralgia, worms 
in the intestinal canal,* etc. The cardiac o^ano^lia are rendered irritable 
by the excessive use of tea, coffee, tobacco, spirits, etc. The excitor 
apparatus of the sympathetic may be the seat of a disturbance, as in 
Grave's disease, etc. 

Symptoms. — There may or may not be, previous to the attacks of 
palpitation, any symptom of trouble in the heart. When such prelim- 
inary symptoms are felt, they consist of a vague sense of uneasiness, 
prsecordial oppression, or dull pain. There is no fixed period for the 
attacks, unless excited by some habit or custom, as eating, smoking, 
etc. ; neither have they any special duration, but may last from a few 
minutes to some hours, or a day. The attack consists of a rapid and 
tumultuous beating of the heart ; dyspnoea, anxiety, and an hysterical 
sense of choking accompany the beating ; the heart seems almost to 
turn over, to rise up into the throat ; the recumbent posture can not 
usually be borne, especially lying on the left side, and the sitting pos- 
ture, leaning somewhat forward, is the most comfortable position ; 
there are also experienced more or less vertigo, faintness, flashes of 
light, coldness of the surface with cold sweating and a very weak 
pulse, or it may be the surface is warm and perspiring, the pulse full 
and strong. The face may be pale or flushed, but is always expressive 
of anxiety ; speech is difficult, or is arrested. The physical explora- 
tion, if no cardiac lesion exist, is merely negative. The movement, if 
very rapid, can not be separated into its component parts. Examina- 
tion must be made, in the interval of the seizures, to ascertain the real 
condition of the heart. The duration of the attacks, as already stated, 

* Case of Dr. Cotton ("The British Medical Journal," June, 1S37), in which the pul- 
Bationa were 240 per minute, and ceased on the evacuation of a tape-worm. 



332 



DISEASES OF THE BLOOD-VESSELS. 



is very variable. The beating may subside in a few minutes, or sev- 
eral hours may be occupied in returning to the normal. At the con- 
clusion of the paroxysm, a quantity of pale, limpid urine is usually 
passed, and there is a strong sense of fatigue and exhaustion, with a 
tendency to sleep. 

Treatment. — Prophylaxis is important. The vice, of whatever 
kind, on which the attacks depend, should be removed. Tea, coffee, 
and spirit drinking must be given up ; errors of digestion, reflex dis- 
turbances, and curable diseases must be corrected or cured. The hy- 
giene of the individual must be carefully investigated, and sources of 
disturbance be put aside. The general health must be maintained at 
the highest point of efficiency. In the absence of any explanation of 
the paroxysms, the presence of a tape-worm may be suspected. For 
the immediate relief of the paroxysm, there is no remedy so efficient 
as the hypodermatic injection of morphia. If the surface is pale and 
the extreme vessels contracted, inhalation of nitrite of amyl (two or 
three drops) affords prompt relief. The inhalation of ether is also 
effective. All narcotic agents must be used with caution, because of 
the certainty, if the attacks are frequent, that the habit of their abuse 
will be formed. The application of cold, in the form of an ice-bag to 
the prsecordial space, is an effective means of quieting the heart. The 
galvanic current, from ten to thirty or forty elements, passed through 
the pneumogastric and cervical ganglia of the sympathetic, often gives 
great relief. If there is no cardiac disease, chloral is an efficient quiet- 
ing agent, and the bromides may also be given with good results. 



DISEASES OF THE BLOOD-YESSELS. 



ARTERITIS— INFLAMMATION OF THE ARTERIES. 

Definition. — The acute form of arteritis is uncommon, and is rather 
a surgical than a medical topic. Chronic arteritis, on the other hand, 
is not only a common but it is an extremely important disease. It 
has received various designations, as endarteritis^ atheromatous arte- 
ritis^ arterial sclerosis, arteritis deformans, etc., intended to indicate 
the nature of the change undergone by the vessels. 

Causes. — It is extremely rare before forty, and frequent after fifty. 
Men are probably more liable to it than women, but there is slight 
difference as regards sex. Various cachexise seem to hasten its devel- 



ARTERITIS. 



333 



opment. A fatty change occurs in the intima during the course of 
severe and prolonged anjemia. Chronic alcoholism, the poison of lead, 
gout, rheumatism, syphilis, etc., are supposed to be influential in devel- 
oping the disease at an early period. Functional strain, in accordance 
with a well-known law, tends to excite arteritis ; hence its early ap- 
pearance in the aorta. Sometimes aortitis is derived, by contiguity of 
tissue, from endocarditis. 

Pathological Anatomy. — The initial change consists in a prolifera- 
tion of the connective-tissue corpuscles of the intima ; the young cells 
crowd the space between the lamellae, and, pushing up the intima, 
form a projection about a line above the general level. This abun- 
dant formation of new cells requires an amount of pabulum which can 
not be supplied, and hence the proliferating cells undergo a fatty de- 
generation. While this process is going on, a solution of the basis 
substance (the connective-tissue matrix) takes place.* This change 
appears to the naked eye as yellowish or yellowish-white opaque spots 
or patches, distributed through the thickened elevations of the intima, 
which become soft and friable, and are gradually detached, leaving an 
abrasion, or "atheromatous ulcer." These abrasions may be coated 
with masses of fibrin, or blood-clot may form on and adhere to them. 
Coincidently with the process of fatty metamorphosis, another process, 
beginning also in the sclerosed intima, develops. This consists in a 
deposition of calcareous material — the lime salts, chiefly — in the basis 
substance of the intima, and between the lamellss. Plates of consid- 
erable size are thus formed in the aorta ; they may be several inches 
in length, and of a curved shape corresponding to the aortic curve, 
and may extend over one half, even more, of the circumference of the 
vessel. Their rough surfaces project through the innermost lamella 
into the vascular lumen. These two processes very frequently coin- 
cide. The alterations taking place in chronic arteritis are not confined 
to the intima, but the media and the adventitia also participate. The 
unstriped muscular fiber undergoes fatty metamorphosis and calcifica- 
tion, or disappears by simple atrophy. In advanced cases the adven- 
titia inflames, becomes infiltrated with cells, or undergoes fibroid 
degeneration. The results of arteritis are very important ; when the 
small vessels are affected, their lumen is encroached on and may be 
entirely obstructed, or a large number affected to a less degree, the 
amount of blood passing to the district supplied by them will be much 
reduced, and important nutritive alterations must occur. The changes 
in the tunics of the vessels especially involve their elasticity, and they 
become mere rigid cords, through which the blood passes in jets. The 
loss of the power of elastic recoil exposes them to injury as the blood 
is driven through, and they slowly dilate or yield in places, forming 

* Rindfleisch, op. cit.^ p. 211, seq. 



334 



DISEASES OF THE BLOOD-VESSELS. 



sacculi, or are torn outright. The increased resistance to the propulsion 
of blood, caused by these changes in the arteries, leads to dilatation 
and hypertrophy of the left ventricle. ISTamed in the order of relative 
liability to arteritis deformans, are the aorta, the cerebral arteries, the 
coronary, the arteries of the extremities, and, lastly, the arteries dis- 
tributed to the organs of vegetative life. 

Symptoms. — The symptoms are obviously of a very diverse charac- 
ter when produced. Kothing is more usual than to see men after fifty 
with extensive atheroma, without a single symptom referable to it. 
^Nevertheless, numerous and important consequences follow arteritis in 
some situations, and at certain stages of its development. Arteritis 
of the aorta, and the cardiac disturbances due to it, and arteritis of 
the brain, and the structural alterations produced by it, are the same 
as regards the arterial change, but are widely different in respect to 
the symptomatology. If the lumen of the aorta is encroached on, 
especially if very great narrowing takes place at the bifurcation of 
large arteries, or if extensive arterial districts have undergone sclero- 
sis, the work of the heart to distribute the blood is so much increased 
that the organ undergoes hypertrophy. This change is indicated by 
the heaving impulse, by an extension of the area of cardiac dullness 
downward and to the left, and by accentuation of the second sound. 
Murmurs, due to regurgitation or stenosis, or both, may be audible 
with greatest intensity in the aortic area, when an extension of disease 
from the aorta to the semilunar valves, or to the endocardium, takes 
place. Weakening of the heart, dyspnoea, general oedema, may finally 
occur from degenerative changes in the heart-muscle, the result of 
atheroma and calcification of the coronary artery. The physical signs, 
then, of hypertrophy, from the causes above mentioned, must neces- 
sarily disappear and be supplanted by others when the aortic valves 
and the cardiac tissues become diseased. Dilatation of the ascending 
aorta may produce a pulsation in the right second intercostal space 
that may be mistaken for aneurism, and, if the dilatation be consider- 
able, some dullness on percussion may be developed in the same posi- 
tion. The changes of arteritis deformans may be studied clinically in 
some superficially placed arteries, as the radial and the temporal ; they 
are rigid, tortuous, irregular in size, and may be rolled under the skin 
like whip-cord. The tortuosity is increased during the systole, and 
lessens during the diastole, and the pulse is delayed — firm when the 
calcification is beginning, but becoming less and less recognizable as 
the artery degenerates into a calcareous tube. The loss of elasticity 
of the arterial tunics influences the sphygmographic tracing, which 
exhibits the same features as in albuminuria — rounded summits, ob- 
lique descent, without dicrotic or recoil wave. Advanced endarte- 
ritis leads to disastrous results in the nutrition of peripheral parts — 
the fingers and toes. In consequence of the diminished supply of 



ARTERITIS. 



335 



blood, the sensibility is low, the skin bluish, benumbed, and cold, and 
the least injury may set up destructive inflammation. A thrombus 
forming in the principal artery, dry gangrene will follow in the parts 
below, or in a small vessel of the foot ; a single toe, or several toes, 
may slough off. Even more serious results follow endarteritis of the 
internal vessels. Thus, as has been pointed out in the article on gas- 
tric ulcer, solution of the mucous membrane and the subsequent for- 
mation of a chronic ulcer may have its origin in disease of an artery 
and thrombosis. It is a singular fact that, although the arteries of 
the vegetative organs are the last to be invaded by endarteritis, yet 
it occasionally happens that a small part of an artery supplying the 
gastric mucous membrane is the seat of this degeneration, with the 
disastrous effect above mentioned. But the arteries of the brain are 
much more widely and early affected by endarteritis than of any ves- 
sels except the aorta, and indeed this morbid process may begin in the 
brain. The dilatations of the arterioles and small arteries, known as 
miliary aneurisms, are the great cause of cerebral haemorrhage ; throm- 
boses of the capillaries and small arteries induce local softening ; en- 
darteritis, without interrupting the passage of the blood through the 
lumen of the vessels, impedes the transference of the nutritive mate- 
rials to the tissue of the brain, with the result of serious impairment 
of the nutrition of the organ, and consequent failure of mental power, 
and the usual objective evidences of cerebral mischief. 

Course, Duration, and Termination. — The course of endarteritis is 
influenced by various circumstances. The progress of the change is 
hastened by the abuse of spirits, and by such cachexiae as syphilis, 
rheumatism, and gout. It is very chronic, and its duration may be 
measured by years. As has been pointed out, many cases exist with- 
out causing any disturbance ; others are very important in conse- 
quence of the lesions invited by arteritis. The termination is a ques- 
tion of the nature of the secondary lesions, and especially of the 
changes in the cerebral arteries. There is more danger in those cases 
occurring at an early period of life. For example, the author has 
seen life terminated by a small aneurism of the basilar artery, when 
this was the only spot where endarteritis existed. 

Treatment. — Although, when the change has once taken place in an 
artery, nothing can be done to remove it, the author believes that the 
progress may be, if not arrested, at least retarded by proper treatment. 
There are three remedies of special importance in this disease ; qui- 
nine, hypophosphite or lactophosphate of lime, and cod-liver oil. The 
phosphite or phosphate of lime, and the cod-liver oil, should be given, 
after meals — a teaspoonful of the sirup of either phosphate or phos- 
phite, but preferably of lactophosphate of lime, and a teaspoonful of 
cod-liver oil. They may be given in an emulsion simultaneously, or 
one may follow the other, and they should be taken without failure 



336 



DISEASES OF THE BLOOD-YESSELS. 



for montlis at a time. Quinia should be given in five-grain doses, 
morning and evening, on alternate days at various times. Personal 
habits contributing to arterial degeneration should be discontinued. 
A syphilitic taint should be corrected, and lead or other poison depos- 
ited in the tissues should be eliminated. The diet should be composed 
of nutritious materials, but indigestion ought to be avoided. Daily out- 
door air and moderate exercise are very necessary hygienic measures. 

ANEURISM OF THE AORTA. 

Definition. — An aneurism is a tumor formed of the coats of an 
artery, and containing blood and fibrin. They are designated cylin- 
drical, fusiform, or sacciform, according to their shape ; and true if all 
the layers are engaged, false if one or two form the walls of the sac. 
A dissecting aneurism is one in which, the intima and media giving 
way, the blood dissects along underneath the adventitia, and the walls 
of the sac are composed of this membrane only. A varicose aneurism 
is one in which a communication is established with the vense cavae, 
the innominatse, the right auricle, or the pulmonary artery. The ana- 
tomical distinctions on which these names are based are important 
chiefly from the prognostic point of view. 

Causes. — The aorta is the favorite site of aneurisms, because, in the 
performance of its functions, it is subjected to great strain. If the 
left ventricle is hypertrophied, the blood - pressure in the aorta is 
increased, and the tendency to the formation of aneurism is greater. 
Powerful muscular effort has the same effect, and hence those who 
are engaged in occupations requiring the exertion of their utmost 
strength suffer more from this malady than those having easier pur- 
suits. Men are more liable to the disease than women, and for the 
same reason that those who labor hard suffer more. The frequent 
association of syphilitic infection and aneurism has attracted much 
attention, but a causal relation has not yet been established. Chronic 
arteritis is, doubtless, the chief cause ; the tunics of the vessel, weak- 
ened by the structural alterations, yield more and more under the 
force of the blood - pressure. To this view, which is generally ac- 
cepted, is opposed the important fact that, while aneurism is most 
usual between thirty and forty, atheroma rarely sets in until after 
forty. On the other hand, it may be alleged that aneurism would be 
vastly more frequent if the changes in the structure of arteries oc- 
curred earlier in life ; and, furthermore, in cases of aneurism, the 
existence of atheromatous degeneration can almost always be ascer- 
tained. 

Pathological Anatomy. — In Sibson's * collection of cases of aneu- 
* Sibson's " Medical Anatomy," London, 1CG9 (sec columns 57-60). 



ANEURISM OF THE AORTA. 



337 



rism occupying some part of the aorta, 880 in number, 703 were of 
the thoracic aorta, the others of the abdominal and its branches. Of 
these, 193 were of the ascending aorta, 87 occurring at the sinuses 
of Valsalva. This statistical fact is a confirmation of the pathologi- 
cal law that those parts most subject to strain in the ordinary course 
of functional work soonest become diseased. ISText to the ascending 
part, comes the arch which was the seat of aneurism in 120, while 
only 72 were in the descending aorta. As regards the form assumed 
by the aneurism, two thirds of those affecting the ascending part are 
examples of the sacculated variety. It is a curious fact that, while 
aneurisms of either the ascending or transverse aorta are sacculated, 
those involving both parts of the vessel are cylindrical or fusiform 
(Sibson). In the descending aorta, the sacculated are about two 
thirds of the whole number. The direction taken by the aneurism 
of the ascending aorta is usually to the right of the transverse part, 
about one half toward the back, the other half to the right and front ; 
of the descending, to the left and posteriorly. 

The sac of the aneurism, which in the beginning is composed of 
the tunics of the vessel, or of the adventitia, is subjected to various 
pathological influences which alter its character. It is affected by 
atheroma, by calcification, but is still more changed in structure by 
attacks of inflammation which unite it to neighboring organs. The 
author has met with a case in which the proper sac had disappeared, 
and the walls were made up for the most part of the tissue of the left 
lung in which it was imbedded. The interior of the sac is altered by 
successive deposits of fibrin, differing in age, color, and density, and 
having a distinctly stratified arrangement. The oldest layers are 
grayish-white, tough, and firmly adherent to the inner surface of the 
sac, while the recent coagula contain more or less coloring matter, 
are softer, easily broken up and detached. By the gradual addition 
of layers of fibrin the sac is ultimately closed, and a cure is effected 
by the obliteration of the cavity. Sometimes the outermost layers of 
fibrin undergo calcification ; sometimes an acute inflammation is set up 
and the sac is destroyed by suppuration. Occasionally blood-clots or 
masses of fibrin are cast off, with the effect to block the efferent vessel, 
or some of its tributaries, or, breaking up, are distributed as multiple 
emboli. The mischief caused by an aneurism is not limited to the sac 
itself, but involves neighboring organs by pressure, interfering with 
functions, or inducing inflammation, ulceration, and atrophy. The 
bronchi, oesophagus, or thoracic duct, may be opened by ulceration, or 
the vena cava occluded by a thrombus, or invaded by ulceration, thus 
producing an aneurismal varix, or atrophy of the neighboring lung 
may be caused by pressure. The ribs, sternum, and vertebrae may be 
eroded, and the spinal cord compressed. Important nerve-trunks are 
first irritated by the proximity of the tumor, next inflamed by pres- 
24 



338 



DISEASES OF THE BLOOD-VESSELS. 



sure, and ultimately so mixed in the elements of the sac as to disap- 
pear. If the aneurism occur in the sinuses of Valsalva, the aortic 
valves become incompetent by reason of changes in the orifice. It 
had been generally maintained that aneurism of the aorta causes 
hypertrophy of the heart, but Sir Dominic Corrigan, Professor Axel 
Key,* of Stockholm, and others, have shown that " aneurism has no 
tendency to produce enlargement of the heart " (Corrigan) ; and, when 
hypertrophy coexists with aneurism, there is no causal connection. 

Termination by rupture is the most common. As regards aneu- 
risms of the sinuses of Valsalva, about eighty per cent, terminated by 
rupture ; of the ascending aorta, fifty-seven per cent, ended by rup- 
ture ; of the transverse, thirty-seven per cent. ; of the descending 
aorta, seventy-five per cent. (Sibson). Rupture of the ascending aorta 
occurs into the pericardium (in one half of the cases), into the right 
auricle, into the lung, into the pleura, into the right bronchus, into the 
trachea, into the oesophagus, or externally ; of the transverse portion, 
into the trachea, lungs, cesophagus, pleura, posterior mediastinum, pul- 
monary artery, or vena cava ; of the descending portion, into the 
pleura, lungs, etc. 

Symptoms. — The signs and symptoms of aneurism, as of cardiac 
diseases, are comprehended in two groups : rational and physical. 
The rational signs are symptomatic of the functional troubles caused 
by the aneurism, and, of course, vary somewhat with the position of 
the new formation. It will conduce to clearness to consider the sub- 
ject of aneurism of the thoracic aorta and its main branches first, and 
follow with aneurism of the abdominal aorta and its main branches. 

AiiewHsm of the Thoracic Aorta. — The earliest symptom is pain. 
This may be a fixed pain, almost constant, and felt in one spot under 
the sternum and in the neighborhood of the aneurism. More fre- 
quently the pain ha^ a combined lancinating and tensive character, 
shooting up from the interior of the chest to the neck, to the shoulder, 
down the arm to the elbow, sometimes to both sides ; or, it is felt in 
the back and shoots around the chest in the direction of the intercos- 
tal nerves. At times the attacks of pain are most severe, and demand 
the use of active anodynes. These pains, which occupy the trajectory 
of the cervical and brachial plexus, and of the intercostal nerves, ought 
not to be confounded with attacks simulating closely angina pectoris, 
which occur when the aneurism is near the heart. These paroxysms 
consist of pr{3ecordial pain and anxiety — pain shooting across the chest, 
in the prjecordial region, and to the shoulder, down the arm. Although 
these attacks are due to the irritation of the nerve -trunks, they affect 
a different set of nerves, those supplying the heart itself. So constant 
is this symptom of pain, so severe and persistent, although paroxys- 



* The "Medical Times and Gazette," June 4, 18Y0. 



ANEURISM OF THE AORTA. 



339 



mal, that, if it come on in a man of middle age without any explanation, 
aneurism should be suspected in the absence of more characteristic symp- 
toms. There is also more or less dyspnoea, paroxysmal rather, in the 
initial period, and may occur without any apparent cause, from pres- 
sure on the pneumogastric when there is apt to be nausea associated 
with it, or to pressure on the phrenic, when there may be hiccough. 
In the further development of the aneurism, dyspnoea may be pro- 
duced by pressure on the left primary bronchus, diminishing the air 
passing to the left lung or on the trachea, or to pressure interfering 
with the return of blood from the lung, and there may be simultane- 
ously pressure on the pneumogastric, causing laryngeal symptoms, and 
on the phrenic, causing paralysis of the diaphragm. When the dysp- 
ncea is due to pressure on the recurrent laryngeal, there will be asso- 
ciated with it peculiarities of the voice, cough, and breathing. When 
due to pressure on the trachea, it is somewhat relieved by inclining the 
head forward ; and in one case, that of a physician seen by the author, 
a violent suffocative attack was brought on by raising the head erect. 
In other cases of pressure on either bronchus, relief to the breathing 
is afforded by turning to the opposite side. When the dyspnoea is 
due to direct pressure on the lung, there are present fever, profuse 
expectoration, etc., the signs of phthisis. When the aneurism is at the 
arch and springs from the inferior segment, pressure on the recurrent 
laryngeal will produce characteristic symptoms at an early period. If 
the pressure irritates without destroying the nerve, all of the muscles 
of the larynx innervated by it will be thrown into a state of spasm, 
with the effect to modify the voice and cough in a most characteristic 
manner. While one cord approximates its fellow and vibrates in the 
normal manner, the other is in a state of rigidity and does not vibrate 
normally, producing an odd effect on the voice, there being a double 
tone, one high-pitched and the other lower ; but this vox anserina 
occurs with both inspiration and expiration. Alteration of the voice 
is much more common than aphonia. When the paralysis of the vocal 
cords is double, which is an extremely rare event, the voice is gone 
and there is aphonia ; but, if, as is usually the case, the paralysis is of 
the left vocal cord, the voice has a harsh, stridulous character. The 
cough exhibits the same peculiarities. When the nerve is irritated 
without being destroyed, the cough is loud, resonant, and metallic — 
croup-like ; on the other hand, when the nerve is destroyed and the 
muscles of the larynx paralyzed, the cough is suppressed, wheezy, strid- 
ulous. By laryngoscopic examination, the explanation of these phe- 
nomena is afforded in the character of the movements of the arytenoid 
cartilages and vocal cords. The effect of irritation is seen in the rigid 
state of one cord, which does not approximate accurately its fellow 
during phonation, and vibrates imperfectly if at all. When the de- 
struction of the nerve is effected and paralysis comes on, the paralyzed 



340 



DISEASES OF THE BLOOD-YESSELS. 



vocal cord is relaxed, wrinkled, and does not move up to its fellow 
during phonation, nor does the inspiratory dilatation take place on the 
paralyzed side. Irritation of the main trunk of the pneumogastric 
may, as has been pointed out, cause respiratory disturbances, par- 
oxysms having an asthmatic character, etc., but the peculiarities of 
voice and speech above mentioned are only produced by lesions of the 
recurrent laryngeals, and chiefly of the left nerve. Several cases of 
bilateral paralysis of the larynx have resulted from the pressure on the 
nerve of one side only. Dr. George Johnson * supposes this to be due 
to a reflex influence transmitted by the commissural connection be- 
tween the nuclei of the spinal accessory, and this is most probably the 
true explanation, although it has been opposed. 

The state of the pupil has a high degree of clinical importance. 
If the aneurism irritate the fibers of the sympathetic nerve without 
destroying them, this fact is signalized by permanent dilatation of the 
pupil ; but if the nerve-fibers are destroyed, paralysis of the radiating 
fibers of the iris ensues, and hence contraction of the pupil follows 
(the third pair unoj^posed). Usually sjDasm of the glottis (irritation 
of the inferior laryngeal) coincides with dilatation of the pupil (irri- 
tation of the sympathetic) ; but this relation is not invariable, for 
spasm of the glottis may be present with contracted pupil (Russell). 
Unilateral sweating of the head and face is a symptom which occurs 
in a small proportion of cases, and may or may not be coincident with 
changes in the pupil. The sweating is strictly limited to one side of 
the head and face, and, although increased by external warmth and 
exercise, comes on quite independently of external conditions. It is 
supposed to indicate irritation of the sympathetic, but the real nature 
of the phenomenon is as yet unknown. As unilateral sweating is pro- 
duced by a variety of causes, it is of importance in this connection 
only when it coincides with other and more definite signs. 

The character of the cough associated with laryngeal troubles has 
been mentioned. There is also cough when the lungs are involved, and 
sometimes profuse expectoration. Cough is a symptom of pressure on 
the trachea or bronchi. Expectoration of blood from a minute com- 
munication between the sac of the aneurism and trachea is one of the 
puzzling symptoms, for it may have all the characteristics of an ordi- 
nary pulmonary haemorrhage. This escape of blood may continue for 
several weeks by a circuitous channel, before rupture finally occurs. 
Dysphagia or difficulty of swallowing is produced by the same mechan- 
ism as the laryngeal spasms : irritation of the pneumogastric is reflected 
over the motor branches distributed to the oesophagus. This does not 
continue a permanent disability, but persists for a few hours, then dis- 
appears, to return again at some uncertain period. Pressure of the 

* "The British Medical Journal," December 19, 1874. 



ANEURISM OF THE AOKTA. 



34:1 



aneurism on tlie oesophagus produces a more permanent dysphagia, and, 
as might be expected, is a more common symptom in aneurism of the 
descending aorta than in any other position. According to the statis- 
tics of Sibson, dysphagia was present in thirty-five per cent, of cases of 
the descending aorta, in thirty-one per cent, of those of the arch, and in 
only two per cent, of those of the ascending aorta. As the aneurism 
enlarges, important symptoms are produced by pressure on the great 
vessels. If the descending cava is obstructed, bilateral oedema of the 
face and arms follows, or, if the innominata only is compressed, the 
effusion is limited to the right side or to the left side, according as it 
is the right or left vein. When the right auricle is impinged on, there 
must ensue cyanosis, general venous stasis, and dropsy ; when the left 
auricle, pulmonary congestion with its consequences — brown-red indu- 
rations, hgemorrhagic infarctions, etc. Dilatation of the lymphatic ves- 
sels will be produced by the pressure of an aneurism occupying the 
last portion of the arch and the descending aorta. 

When an aneurismal tumor protrudes at the thoracic wall, the diag- 
nosis by the physical method becomes much simplified. By palpa- 
tion, the existence of a tumor, pulsating and swelling with each pulsa- 
tion, is made out. The first beat is stronger and more prolonged than 
the second, if there are two, and is a little subsequent to the heart- 
beat, while it anticipates the radial pulse. The second corresponds 
to the diastole of the heart, and is the recoil from the closure of the 
aortic valves, and of course is indistinct or wanting when the aortic 
valves are incompetent. A double pulsation exists only in the case 
of recent aneurism, and of the thoracic aorta ; old aneurisms, lined 
with thick layers of fibrin, or composed of bony tissue, can not be 
thrown into vibration by the comparatively feeble force of the recoil 
wave, and abdominal aneurisms lie at too great a distance. Palpa- 
tion also reveals a peculiar thrill or tremor which is intermittent, or 
is synchronous with the first beat, and is known as aneurismal thrill. 
It is obvious that, to feel this, a tumor must be very superficial, and 
without dense, thick, or bony walls. In the case of aneurisms deeply 
placed in the thoracic cavity, these symptoms ascertainable by palpa- 
tion are wanting. Dullness on percussion is elicited only when the 
aneurism has attained sufficient size or is in a position to cause the reac- 
tion, and it exists over a very limited area under any circumstances. The 
usual position of the dullness is on the right of the sternum, parallel 
with the second or third rib ; or it is at the sternum, or to the left of 
the sternum, and posteriorly to the left of the spinal column. This 
symptom does not afford precise indications, since the dullness of an- 
eurism does not differ from that caused by any tumor, or by a solid 
organ, or by a purulent depot. On auscultation we hear in aneurism 
a systolic and diastolic sound or shock, such as is audible over the ar- 
tery itself. These sounds correspond to the pulsations, with the excep- 



342 



DISEASES OF THE BLOOD-VESSELS. 



tion, however, that a diastolic sound may occur when there is a systolic 
and not a diastolic pulsation. The mechanism of their production is 
obvious enough, the systolic sound being due to the vibration of the 
column of blood propelled into the sac, and the diastolic to the recoil 
from the shutting of the aortic valves. The second or diastolic sound 
has a " booming " quality, and is heard the more perfectly the nearer 
the heart the aneurism is placed. When there are cardiac murmurs of 
stenosis or insufficiency, or peculiarities of accentuation, they are prop- 
agated to and are audible over the aneurism. The fitness of the expres- 
sion, that when aneurism is present "two hearts are beating in the 
chest," is quite obvious ; so close, indeed, is the resemblance that the 
sounds heard in aneurism were considered by Laennec as cardiac en- 
tirely. Murmurs also occur in aneurism with, or take the place of, 
the sounds ; they are formed in or of the sac, and are not propagated 
from the heart. They are by no means common, and a diastolic mur- 
mur is greatly less frequent than a systolic. They are produced by 
some irregularity in the interior of the sac, or by pressure on a neigh- 
boring vessel, or on an adjacent part of the aorta. A sacculated an- 
eurism does not, but the other varieties do in some cases, retard the 
pulse-beat. If it occupy the ascending aorta the pulse will be behind 
on the whole round of the circulation ; if the transverse portion of the 
arch and between the arteria innominata and the left subclavian, the 
pulse of the radial will be retarded ; if the descending aorta, the fem- 
oral pulse will be delayed. The pulse is also changed in character. 
If the orifice of the efferent vessel is unobstructed, the normal dicro- 
tism of the pulse is increased because of the secondary undulation im- 
parted to the blood-column ; on the other hand, if the efferent vessel 
is narrow or obstructed, the pulse is small, irregular, and without 
dicrotism. 

The symptoms of aortic aneurism vary with the position of the sac 
in the course of the vessel. In aneurism of the ascending part there 
are pressure on the right auricle, cyanosis, venous stasis, and dropsy. 
The aortic valves are usually incompetent, and the murmurs thus pro- 
duced are audible over the sac. As the tumor develops anteriorly, the 
pulsation is felt in the second or third right intercostal space at the 
border of the sternum. When it projects it forms an hemispherical 
tumor, having, usually, a double pulsation, a reddish and purplish Lint, 
is crossed by enlarged and varicose veins, and presently softens. The 
radial pulse is retarded equally on both sides, unless compression of the 
innominate artery occurs. The laryngeal symptoms, so constant in 
aneurism of the arch, are wanting, but the pupillary phenomena and the 
unilateral sweating may be present. The trachea and oesophagus are 
occasionally encroached upon, but the right primary bronchus may be 
compressed. In about one half of the cases the pulmonary artery and 
the adjacent right ventricle are impinged on. According to the data 



ANEURISM OF THE AORTA. 



343 



of Sibson, aneurisms of the ascending aorta compressed the right lung 
in thirty-four instances, the left lung in ten, the right bronchus in six, 
the left bronchus in one, the pulmonary artery in seven, the descending 
vena cava in sixteen, and the trachea and oesophagus in nine each. In 
aneurism of the arch there will be oedema of the head and upper ex- 
tremities ; the pupil will be affected but not invariably ; laryngeal 
symptoms will be usually present from compression of the left recurrent 
nerve ; there will be compression of the left primary bronchus, and 
consequent feeble respiration or collapse of the left lung ; there will 
be dysphagia from obstruction of the oesophagus sometimes ; attacks 
of angina pectoris from irritation of cardiac nerves. Referring again 
to the facts of Sibson, we find in regard to aneurism involving both the 
ascending and transverse aorta, that there were present dyspnoea in 
74 per cent., orthopnoea in 21 '5, cough in 47, haemoptysis in 10, stridu- 
lous breathing or affection of voice in 17, dysphagia in 21*5, the head 
and neck were swollen in 14 per cent. ; w^hile in aneurism of the trans- 
verse aorta alone there were present, dyspnoea in 71 per cent., orthop- 
noea in 20 per cent., cough in 57*5 per cent., haemoptysis in 19 per cent., 
inspiration stridulous in 47*5 per cent., dysphagia in 31 per cent., the 
pulse weaker in one wrist in 26 per cent. As regards the descending 
part of the arch of the aorta, we find that the vertebrae were eroded 
in 42 per cent. ; the tumor made pressure on the trachea in 12*5 per 
cent., on the left primary bronchus in 37*5 per cent., on the oesophagus 
in 31 per cent., the left lung in 48 per cent. ; dyspnoea occurred in 50 
per cent., cough in 46 per cent., the voice affected in 25 per cent., and 
dysphagia existed in 33 per cent. The important disturbances arising 
from aneurism in this situation are obviously due to the recurrent 
laryngeal nerve, left primary bronchus, oesophagus, and trachea, which 
come into close relation with the vessel at this point. Aneurisms lower 
down compress the left lung, and cause erosion of the vertebra? in 74 
per cent. There is a fixed boring pain about the site of the aneurism 
in one half the cases ; there is also much pain in the intercostal nerves ; 
the femoral pulse is retarded ; and, when the spinal canal is invaded, 
disorders of sensation and of motility occur in the lower limbs, termi- 
nating in hemiplegia. A case is reported of an aneurism of the arch, 
dissecting downward between the trachea and oesophagus and bursting 
into the stomach. The symptoms were orthopnoea, dysphagia, and 
stricture of the oesophagus, but not of aneurism.* 

Aneurism of the innominata causes very much the same symptoms 
as the first part of the arch : a systolic and a diastolic pulsation ; a 
double sound, synchronous with the cardiac, and audible with the 
greatest intensity at the junction of the clavicle and sternum ; retar- 
dation and increased dicrotism of the right radial pulse if unobstructed 

* "Pathological Society's Transactions," vol. xxvii, p. 91, report of Dr. Frederick Taylor. 



DISEASES OF THE BLOOD-VESSELS. 



at orifice of exit ; pain in the neck and arm ; compression of the de- 
scending vena cava, and oedema of the head and upper extremities, or 
there may be compression of the left vena innominata, and consequent 
oedema of the left side of the head and the left arm. 

Aneurism of the Abdotninal Aorta. — The point of election is at or 
near the coeliac axis. In Dr. Sibson's collection of cases, 177 in num- 
ber, 131 occurred at this point. Less than one half arise from the an- 
terior face of the vessel, and consequently the vertebrae are eroded in 
a large proportion of cases — 55 per cent. The variety of the aneurism 
is the so-called false, and the form sacculated in 60 per cent., and they 
attain considerable size, sometimes to a capacity of ten pounds. 

Aneurism of the abdominal aorta is usually referred to a violent 
muscular effort — always, in the author's experience. It appears to be 
less associated with atheromatous degeneration of the arteries than is 
aneurism of the thoracic aorta. One of the earliest symptoms is pain, 
felt in the position of the tumor and radiating through the abdomen. 
As the aneurism is so situated that the semilunar ganglion and the 
nerves of the solar plexus must be compressed by it, pain is necessarily 
produced, and, as the nerves radiate from a common center, the pain 
also radiates, shooting up into the hypochondria and downward to the 
iliac regions and hypogastrium. These pains are paroxysmal, and may 
disappear for hours and days ; but the attacks are of extreme severity, 
and when they subside leave the patient exhausted. The local pain 
seems to the patient to be in the stomach, and, as this organ is disturbed 
in function also, the attacks are often confounded with gastralgia. This 
local pain is more constant than the other, and there is rarely an entire 
cessation of it, although it may be little more at times than an uneasi- 
ness. In about one half of the cases the most violent pains occur in 
the back, and shoot down through the lumbar region into the hips 
along the course of the sciatic nerves. There is here also a fixed^ 
boring pain felt opposite the coeliac axis, which is rarely absent. In 
both situations the pains are aggravated by pressure, by sudden jolt- 
ing, or bending the body. The pain in front is increased by taking 
food, especially by distention of the stomach. Distress produced by 
eating, indigestion, flatulence, and nausea, are early symptoms, due to 
irritation of the solar plexus. As the pain is brought on by eating, 
and as pronounced stomach troubles are present in a majority of the 
cases, it need occasion no surprise that they are often supposed to be 
entirely stomachal. This mistake is persisted in even when a tumor is 
present, and the phenomena are then ascribed to cancer of the stomach. 
This mistake is all the more readily made, since the interference with 
digestion brings on a cachectic state with wasting, and since jaundice 
may be caused by pressure on the common duct. The stomachal dis- 
orders are less pronounced in those aneurisms springing from the pos- 
terior part of the aorta and making their way posteriorly. According 



ANEURISM OF TEE AORTA. 



345 



to Sibson, a pulsating tumor was observed in 55 per cent, of the cases. 
A large tumor may form posteriorly, and produce extensive erosions 
of the vertebrae, without being ascertained by the most careful palpa- 
tion. A dislocated kidney, a migrating spleen, a bunch of enlarged 
Ivmphatics, may rest on the aorta and receive a pulsation synchronous 
with the cardiac systole. In applying the method of palpation, to de- 
termine the nature of a pulsating epigastric tumor, the sources of error 
just mentioned must be eliminated by putting the patient in such a 
position that these bodies will fall away from the aorta, when, of course, 
the pulsation will cease. The aneurismal tumor is situated usually in 
the epigastrium, a little to the left of the median line. It is a globular, 
elastic tumor, pulsating with an expansile movement in all directions, 
and on inspection there will be seen a swell of the whole abdomen with 
each pulsation. The pulsation of an abdominal aneurism is single, a 
little later than the cardiac systole, and there is usually a thrill. If 
pressure is made on the aorta below the aneurism, the sac will be filled 
with a stronger impulse, and retain its fullness, while the thrill ceases 
or is less marked. Percussion is of little value. Dullness may be elicit- 
ed under favorable circumstances, but this affords no indication of the 
nature of the producing cause. Murmur is present in a considerable 
proportion of cases. It has a blowing character, is rather soft, and, in 
time, is a little later than the cardiac systole. "When the aneurism 
springs from the anterior surface of the aorta, the murmur is audible 
in front, and, when the growth is posterior, audible behind ; rarely is 
it audible in both situations in the same case. Standing erect arrests 
the murmur, because, according to Corrigan, of the increased tension 
in the sac produced by the superincumbent column of blood. To this 
statement and explanation must be opposed the important fact that 
the murmur was audible in the erect and ceased in the recumbent pos- 
ture in an undoubted case of aneurism. Aneurism of branches of the 
aorta are occasionally encountered. An aneurism of the mesenteric 
artery is a movable tumor which may be confounded with floating 
kidney.* It differs from the latter in being globular and pulsating. 
Aneurism of the hepatic artery may cause jaundice, by pressure on 
the duct, or ascites, by pressure on the portal vein. As they are small 
in size and deeply placed, aneurisms of the hepatic artery are rarely, 
if ever, recognized during the life of the individuals affected by them. 

Course, Duration, and Termination of Aneurisms of the Aorta. — 
The course of aneurism is much influenced by the condition of organs 
compressed, and the disturbances of function thus induced. They are 
essentially chronic, slow in development usually until of sujfficient size 
to compress the organs about them, when symptoms are caused which 

* Dr. Burney-Yeo communicates a case to the Pathological Society ("Transactions," vol. 
xxviii, 1877), in -which the first part of the artery was affected and not movable. It com- 
pressed both renal arteries, and caused death by uraemia. 



346 



DISEASES OF THE BLOOD-VESSELS. 



attract attention to them. 'Not all cases give rise to symptoms that 
indicate the cause of the disturbances which they produce ; only the 
disturbances are recognized and treated as the real malady. Thus, 
aneurisms deeply placed in the thorax posteriorly, or of the abdominal 
aorta, high upon between the crura of the diaphragm, or growing 
toward the lumbar region, may produce no symptoms which can indi- 
cate the nature of the disease. Even when a tumor of considerable 
size exists, in the situation most favorable for recognition, grave 
doubts may be entertained as to its aneurismal character. They may 
terminate in a variety of modes ; by exhaustion, by pneumonia, by 
rupture and haemorrhage. Probably the most useful collection of sta- 
tistics showing the course and terminations of aneurism is that of 
Sibson, and the author prefers, therefore, to illustrate these points 
from it. As regards aneurism of the first part of the aorta (sinuses 
of Valsalva), we find that 80 per cent, terminated by rupture, 45 per 
cent, into the sac of the pericardium, 13*5 per cent, into the pulmonary 
artery, 8*5 per cent, into the right auricle, 5 per cent, into the right 
ventricle, and 5 per cent, into the left ventricle. Aneurism of the 
ascending aorta " ruptured in 57 per cent. ; externally in 8, into the 
pericardium in 22, into the pulmonary artery in 4, into the descending 
vena cava in 5, into the right lung in 5, into the left pleura in 4, " etc. 
In a series of 25 cases published in the "New York Pathological 
Transactions," the termination was by rupture ; and in almost all of 
the cases death occurred suddenly, but few of them having been diag- 
nosticated. Aneurisms of the ascending aorta and arch conjointly rup- 
tured in 37 per cent., into the pericardium in 10, into the vena cava 
4, into the trachea 4, etc. Aneurism of the descending part of the 
arch ruptured in 75 per cent., into the trachea in 4, into the left bron- 
chus in 16-5, into the left pleura in 23, into the right pleura in 12*5, 
etc. Aneurism of the abdominal aorta ruptured in 77 per cent., into 
the peritoneal cavity in 28*5 per cent., into the subperitoneal tissue, in 
the left hypochondriac region, 22 per cent., etc. Although death is 
almost immediate when an aneurism ruptures, yet this is not invaria- 
bly the case. A small opening may exist in the trachea, permitting a 
little blood to escape from time to time, simulating pulmonary hsem- 
orrhage, and continuing to discharge in this way until a complete rup- 
ture occurred at the end of several months. These are called " weep- 
ing aneurisms." GairSner f records a case of this kind in which the 
opening was blocked by some fibrin, and continued so for four years. 
An opening externally may discharge slowly, of which notable exam- 
ples have been published — a free and fatal hemorrhage being pre- 
vented usually by a plug of fibrin. As the beginning of an aneurism 
is very uncertain, it is difficult to state its duration within exact lim- 

* Tabulated in " Transactions of the London Pathological Society," vol. xxix. 
f " Clinical Medicine," op. cit. 



ANEURISM OF THE AORTA. 



347 



its. They vary exceedingly in duration ; from fifteen days to thirty 
years are the extremes which have fallen under the author's notice. 
Much depends on the influences, medicinal and moral, to which the 
patient is subjected. Some cures are effected. 

Prognosis. — Aneurism must be regarded as a very grave disease. 
Under the improved methods of medical treatment now available, 
more cures are effected than formerly, and the question of treatment 
must enter largely into prognosis. Under any circumstances, a quali- 
fied opinion only should be given, for an aneurism that is apparently 
solidifying may take an unfavorable turn, and death be caused by 
some intercurrent malady. 

Treatment. — The object of the medical treatment of aneurism is to 
secure the solidification of the sac. As this has occurred several times 
spontaneously, without the intervention of art, it is more difficult 
to assign to remedies their exact share in any successful treatment. 
To obtain coagulation of the blood in the sac and to elfect the solidi- 
fication of the fibrin are the objects before us. If we have to deal 
with a sacculated aneurism, the closure of the sac can be accomplished 
without interrupting the current through its proper channel. The 
importance of this is very obvious in dealing with the aorta, for no 
collateral circulation is here possible. The difficulty of a case is im- 
mensely increased from the therapeutical standpoint, when we have to 
treat a dilated vessel. The treatment by rest, as absolute as can be 
maintained, is a very old method, and has much to recommend it even 
now. If the patient maintains a position of recumbency, and moves 
in that position as little as possible, the action of the heart is slowed 
and its force lessened, so that the blood in the sac may coagulate. 
Formerly, the abstraction of blood and an absolute diet were com- 
bined with rest in the recumbent posture (Valsalva's plan), but, in the 
more recent method of Tufnell, only the rest and a restricted diet are 
considered necessary. The diet of this plan consists of two ounces of 
liquid and four of solid food morning and evening, and four ounces 
of liquid and six ounces of solid at mid-day.''^ In addition to this re- 
stricted diet, the blood-pressure is reduced by the daily use of laxa- 
tives. The period of confinement to a recumbent posture is from 
eight to thirteen weeks. The results obtained by Mr. Tufnell are cer- 
tainly very satisfactory, for he has reported cases of aneurism of the 
abdominal aorta solidified in thirty-seven and twenty-one days, and 
one of popliteal cured in twelve days ; and he affirms that, " if the 
plan of treatment by position be but steadily and persevieringly car- 
ried out, a successful issue can (in suitable cases) almost be guaran- 
teed." In addition to rest, arterial sedatives are sometimes given, with 
the view to keep the action of the heart still lower than that rate of 



" Mcdico-Chirurgical Transactions," vol. xxxix, 1874, p. 83, et seq. 



348 



DISEASES OF THE BLOOD-VESSELS. 



movement att-ainable by rest merely, according to Tufnell's plan. The 
arterial sedative employed for this purpose is the tincture of veratrum 
viride, given to bring down and to keep the pulsations about fifty per 
minute. The author has witnessed successes obtained in this way. 
Bloodletting is admissible in cases of large aneurism, a rupture being 
threatened by violent action and plethora. Recently, important re- 
sults have been obtained by the free administration of the iodide of 
potassium (gr. xv — 3j) three times a day. It has a remarkable influ- 
ence over the pain, probably because of its effect in diminishing the 
tension of the sac, the force of the heart, and the blood-pressure (Bal- 
four). Besides this, the iodide seems to affect the sac itself. The use 
of the iodide of potassium may be combined with rest and a lowered 
diet, but these are only adjuvants, and are not essential to the treat- 
ment. Langenbeck has called attention to the great value of ergotin 
as a remedy in aneurism, and has reported some successful cases. It 
has been used since with advantage. Its employment is based on the 
action which it exerts on the muscular fiber of the arteries, and there- 
fore, it is asserted, it can have no effect on the aorta. Those who use 
this argument forget that ergot slows the heart, and raises the blood- 
pressure at the periphery by contracting the arterioles — conditions 
highly favorable to promote coagulation of the blood in the sac. Two 
to five grains of the so-called ergotin, which is the aqueous extract, 
should be administered hypodermatically, simply dissolved in water 
and filtered. This practice may be continued while the other measures 
are being carried out, as there is no therapeutical incompatibility. 
The success which has lately been obtained with barium, based on the 
experimental research of Boehm, is a beautiful example of the value 
of such investigations. From two to five minims of the liquor barii 
chloridi, well diluted, or one sixth grain to one grain of the salt in 
pill form, may be given three times a day, after meals. The physi- 
ological effects of this medicine on the vessels suggested its em- 
ployment originally. Acetate of lead also affects the vessels — espe- 
cially the muscular layer — but there are very obvious objections to its 
long-continued use. Attempts have been made by direct means to 
secure the coagulation of blood in the aneurismal sac. These consist 
in the introduction of fine wires, horse-hair, etc., with the intent to 
supply a foreign body about which the blood will coagulate. Thus 
far, these attempts have been failures, but there has been one success 
reported lately. Another method, of which very confident expecta- 
tions were at one time entertained, is the method of electrolysis. This 
consists in the introduction of an insulated needle into the interior of 
a sac, and the application of a sponge electrode to the exterior, through 
which a galvanic current is passed. The blood coagulates about the 
needle. JVEuch discussion has resulted as to the pole, anode or cathode, 
to be introduced into the sac. As about the positiv^e pole acids, oxy- 
gen, etc., collect, a firmer clot is there formed ; while about the nega- 



TOPOGRAPHY OF THE CHEST. 



349 



tive, hydrogen and the alkalies, producing a softer clot. The positive 
electrode needle is withdrawn with difficulty from, the sac, owing to 
the firmness and adhesiveness of the adherent coagulum, and in mak- 
ing the eifort there is danger of haamorrhage and of setting free mul- 
tiple emboli. On the other hand, although the clot produced by the 
negative needle is less firm, it acts as a nucleus about which denser 
coagula will form afterward. Although cures have been reported by 
electrolysis, this method is not so successful as others recommended 
above. Furthermore, the danger of haemorrhage, of exciting inflam- 
mation, of detaching large clots in the circulation, is so great that this 
plan is not to be commended. 

Aneurism of the coronary artery is a rare disease. Crisp has 
collected and tabulated twelve cases. They occurred from eleven to 
seventy-seven years of age, but chiefly after forty, and in subjects 
exposed to such injury by occupation. They may cause sudden death 
without symptoms, or there may be suffocative attacks, pain, and pal- 
pitations. They vary in size from a pea to a walnut, and rupture into 
the pericardium. This is not the invariable termination, although 
usual, death being caused in three of Crisp's cases by bronchitis, ex- 
haustion, and an unknown cause unconnected with the aneurism. 



DISEASES OF THE BESPIRATORT ORGANS. 



TOPOGRAPHY OF THE CHEST: PHYSICAL DIAGNOSIS. 

The regions into which the chest is divided for the purpose of 
physical exploration are given in Figs. 1 and 2, and the relations of 
the external lines and divisions to the contents of the cavity are shown 
in Fig. 13. The student should fix in his mind, especially, the posi- 
tion of the contained organs, with reference to the exterior anatomical 
landmarks. 

The relations of the heart and great vessels have been discussed 
in the section devoted to diseases of the vascular system. It remains 
now to determine the relations of the lungs, and so much of the heart 
and great vessels as may be necessary to a proper understanding of 
the practice of physical diagnosis in pulmonary diseases. 

In making a physical exploration of the chest, the position of the 
patient should be carefully arranged. In males the chest should be 
entirely bared, and in females covered with a close-fitting chemise or 
flannel undershirt. If the condition of the patient will admit of it, the 

* " Transactions of the Pathological Society,'' vol. xxii, p. 108. 



350 



DISEASES OF THE RESPIEATORY ORGAXS. 



best position for the examination is the erect posture, with the hands 
folded on the hips behind, when the front of the thorax is to be 
explored ; with the arms folded on the chest, and the body slightly 
inclined forward, when the back is to be examined. 

The examination should be conducted in an orderly manner. It 
includes inspection^ palpation^ mensuration^ percussion, and ausculta- 
tion. Some practical observations on these methods may fitly precede 
a study of the maladies in which they are applied. 

Inspection. — By this term is meant a survey of the exterior of the 
thorax ; of its size, shape, deviations from the normal, of its move- 
ments. 

The thorax may be contracted either in consequence of original 
defect, or from disease in early life interfering with the play of the 
lungs. A very common condition is that known as pigeon-breast, the 
ribs having yielded at the sides, giving the sternum an apparent prom- 
inence. The chest of rickety subjects is also comparatively common, 
the pigeon-breast being one of its features, but there are, also, a deep 
groove along the line of junction of the cartilages with the ribs, nodosi- 
ties on the ribs near the cartilages, and flattening of the chest posteri- 
orly, the ribs being rather sharply bent at their angles. By inspec- 
tion, the greater size of one side ; the absence of the proper motion, 
and filling out of the intercostal spaces, or the opposite condition of 
retraction ; bulging at special areas ; retraction of the intercostal space 
at the point of apex-beat, etc., are alterations to be observed. 

By inspection may be noted whether the respiratory movements 
are rhythmical, thoracic, or abdominal. In children and males the 
respiration is largely abdominal ; in females, thoracic. The breathing 
may have the Cheyne-Stokes type ; i. e., beginning with movements nor- 
mal in number, the rate of breathing lessens, and the depth and force 
diminish progressively, until at length breathing seems to be suspended, 
the face becomes cyanosed, consciousness appears to be lost — then, 
with a start, respiration is resumed with increasing frequency until the 
maximum is reached, when again the number of respirations declines 
to zero. 

In beginning an examination of the chest, an attentive inspection 
should be made of the whole thorax during the movements of inspira- 
tion and expiration. 

Mensuration. — For ordinary purposes, a common tape-measure suf- 
fices to ascertain the size of the thorax, of its lateral halves, and of 
special parts deviating from the normal. The circumference of the 
chest is taken at the level of the nipples, and the difference between 
the completest expiration and the fullest inspiration is known as the 
expansive mohility. This difference should be about three inches, but 
practice by developing the chest muscles may greatly increase the 
mobility. No adult chest is normal the expansive mobility of which 
is less than two inches. 



PEYSICAL DIAGNOSIS. 



351 



Palpation. — Important information is had from palpation, which 
consists in applying the palmar surface of the hands to the chest, and 
noting the changes, if any, in the condition of the parts. When the 
fingers are applied to the intercostal spaces, the degree of resistance 
becomes an element of diagnosis. Resistance is increased by any cause, 
of induration of pleura or lungs. When the intercostal spaces are dis- 
tended, as by hydrothorax, or the lung is solidified, the character of the 
resistance is changed from the peculiar elastic quality belonging to the 
parts in a normal state. 

The peculiar vibration imparted to the chest-wall by the voice, by 
the friction of inflamed pleural surfaces, and by the movement of 
mucus in the larger tubes, is called fremitus. Vocal fremitus is pro- 
duced by the voice, as when the patient says in a distinct tone 
" twenty-one," or " ninety-nine," or any similar words. That is tus- 
sive fremitus when caused by cough, and friction fremitus when the 
rubbing together of inflamed pleural membranes imparts a trem- 
bling or vibration to the chest-wall. To ascertain it, the hands are 
placed flat on the chest at various points, according to the situation of 
any morbid process in the thorax. The rhythm of the vibration is a 
point to be noted ; as, for example, when a pleural friction fremitus is 
to be distinguished from a pericardial. Vocal fremitus is increased by 
any cause increasing the density of the pulmonary substance, as in 
pneumonia, phthisis, etc. ; it is lessened by any cause separating the 
lung from the chest-wall. It must be remembered that normally the 
vocal fremitus is greater on the right than the left side, especially over 
the primary bronchus. 

Percussion. — Certain notes are produced by percussion of the walls 
of the chest. The mode of eliciting them is mediate or immediate : 
by the former, a body is interposed — a plessimeter — on which the blow 
is struck ; by the latter, the percussion is made on the chest-wall. 
Plessimeters are made of bone, ivory, or hard rubber, and some of 
them have a scale to mark the dimensions of the part percussed. The 
best plessimeter is the finger, being of material having the same phys- 
ical qualities as the parts percussed, and adapting itself perfectly to 
the surface. If any air is interposed between the plessimeter and 
the surface beneath, the percussion note has a clacking, metallic 
quality. 

The hammer usually employed is composed of the three fingers of 
the right hand, so arranged that their extremities are on the same 
plane. In very delicate percussion, a single finger may be used. The 
best hammer, the author is entirely convinced, is the rubber instru- 
ment now employed for this purpose. With it the sounds produced 
are more uniform, clearer, and better defined. With the finger of the 
left hand as the plessimeter, and the rubber hammer to develop the 
percussion note, the results attained are far better than by any other 
mode. 



352 



DISEASES OF THE RESPIRATORY ORGANS. 



On percussion of the normal chest, a characteristic note is obtained, 
which becomes the standard of comparison for all sounds produced by 
this method. It may be entitled the normal pulmonary percussion 
sound. This normal resonance may be variously altered : it may be 
increased or exaggerated^ or it may be tympanitic in quality. 

The resonance may be reduced below the normal : the percussion 
note may be simply didl^ or it may be entirely flat. When percussion 
is made over a hollow organ, as the trachea, or over a cavity, the note 
is said to be tubular. When the cavity contains air, also, the reso- 
nance has a metallic and hollow character, and is then known as am- 
phoric. A higher-pitched sound, still more metallic in quality, is called 
the metallic. Another percussion-note, similar in quality to the last, 
is the cracked-pot sound, " bruit de pot fele.''^ To produce this sound 
effectively, percussion must be made during expiration, the patient 
keeping the mouth open. The sound may be very successfully imi- 
tated by forming a hollow cavity with the hands folded, and striking 
on the knee. 

Auscultation is the art of hearing the various audible sounds pro- 
duced within the cavity of the thorax, in both healthy and morbid 
states. The ear unassisted can be applied directly to the chest, or the 
hearing function can be supplemented by an instrument called the 
stethoscope. The utility of such an instrument, and the comparative 
value of the various kinds of stethoscopes, have been subjects of 
almost interminable controversy. The majority of physicians prefer 
the wooden cylinder, but the author, on the other hand, finds that the 
Cammann's double stethoscope gives the best results in his own hands. 
The double stethoscope has many advantages ; binaural audition, like 
binocular vision, is more accurate, better defined, and comprehensible 
than uniaural ; the double instrument, by excluding exterior noises, 
conveys the thoracic sounds to the ear with far greater distinctness, 
and thus prevents diversion of the attention from them. The mani- 
fold sounds of a great city interfere in the most perplexing way with 
the chest-sounds, and hence the utility of a binaural instrument. The 
author has found it very useful to employ the unassisted ear, the cyl- 
inder stethoscope, and the binaural in every case involving any diffi- 
culty or obscurity of the physical signs. The defects of the one mode 
of observing may be compensated for by the greater clearness or 
defining power of the other. When the ear is applied directly to the 
chest, a towel or napkin, only, interposed, the method is entitled imme- 
diate auscultation / when the stethoscope is used, it becomes mediate 
auscxdtation. 

When the ear is applied to the chest by mediate or immediate aus- 
cultation, in health, certain sounds appropriate to certain special situa- 
tions are heard. The soft, breezy sound produced by the entrance 
and exit of air from the pulmonary alveoli, is called the respiratory 
murmur — the pulmonary or vesicular murmur. The inspiratory 



PHYSICAL DIAGNOSIS. 



353 



murmur is of longer duration, is louder (higher pitched) than the expi- 
ratory, which may be indeed, and often is, inaudible. The passage 
of air through the larynx and trachea causes a sound of considerable 
intensity, high pitched, and of large volume. This murmur or sound 
begins with the act of inspiration and persists throughout it ; then an 
interval of silence coincident with the time between the respiratory 
movements occurs ; and the sound is resumed with, and continues 
daring, the act of expiration. The expiratory portion of the sound is 
rather higher in pitch, longer in duration, and coarser in quality, than 
is the inspiratory. This murmur, heard by applying the stethoscope 
over the trachea, is the tracheal murmur^ really the laryngeal^ for it 
is caused by the movement of air through the larynx. 

The hroncliial murmur is the sound caused by the movement of 
air through the primary bronchi, or is tracheal in origin but propa- 
gated through the bronchi. It is a coarse, blowing murmur, not so 
high pitched as the tracheal, and is shorter in duration. The interval 
between inspiration and expiration is comparatively short, nor is it so 
distinct as that between the tracheal inspiration and expiration. 

Intensity. — The breath-sounds may be variously modified in inten- 
sity. They may be increased or lessened. When the vesicular murmur 
is simply increased, especially or entirely in inspiration, the change is 
entitled puerile, because of the resemblance to that intensity charac- 
teristic of early life. When lessened in intensity, there is simply a 
diminution in the volume of the respiratory sound communicated to 
the ear, without any necessary change in quality or duration. 

Rhythm. — There are certain changes in rhythm. The most sig- 
nificant of these is the so-called Cheyne-Stokes breathing. This is 
characterized by a deep, prolonged inspiration followed by a succes- 
sion of regularly diminishing respirations until zero is reached, then a 
cessation of respiration of less or greater duration, with a deepening 
cyanosis, and then the resumption of respiration increasing slowly in 
volume and depth until the maximum is again attained. 

Prolonged expiration is a comparatively common alteration of 
rhythm. As has been stated, in the normal condition of the breath- 
ing organs, expiration is comparatively short, feeble, or wholly inau- 
dible ; but it may be greatly prolonged, inspiration continuing the 
same or actually shortening in duration. 

The respiration may be jerky or jumping, affecting chiefly inspira- 
tion, but expiration may have the same character, especially when ab- 
normally prolonged. 

Quality. — The breath - sounds are variously altered in quality. 
They may be simply harsh, or less soft and breezy than normal. 
The increased roughness or harshness may be exaggerated into hlow- 
ing respiration, which is similar to bronchial breathing, except that it 
is higher in pitch and clearer than the latter. Bronchial breathing cor- 
responds in quality to the normal sound, and only assumes a patho- 
25 



354 



DISEASES OF THE RESPIRATORY ORGANS. 



logical character when it becomes audible in unusual situations. Tu- 
bular breathing is an increased or exaggerated bronchial sound. It 
is high-pitched, rather metallic and concentrated, and appears to be 
sounded directly into the ear. 

Cavernous, is a rather low-pitched and hollow sound, produced by 
the vibration of a cavity, and resembles amphoric^ which is a still 
more hollow sound with a somewhat metallic quality. 

Breath-Sounds — Rales. — Certain adventitious sounds caused by the 
movement of the air through tubes in a pathological state are entitled 
rdles by the French ; rhonchi by the English ; but the former is now 
almost exclusively used in this country. A rale is a crackling, hissing, 
whistling, bubbling, or gurgling sound, heard only in inspiration or in 
expiration, or during both of these acts. Rales may be dry or moist. 
Dry rales are distinguished as whistling, or sibilant^ and resounding, 
or sonorous. As the terra implies, they are caused by lesions, affecting 
the diameter of the tubes, without any secretion. 

The most important rales are those due to the presence of an in- 
creased secretion, and the most significant is that rale known as the 
crepitant rdle. This is a fine crackling sound not inaptly compared to 
the crackling of salt thrown on to bright coals, or still more aptly to 
the sound caused by rubbing a lock of hair between the fingers in front 
of the ear, or to the crepitation produced by compression of rubber 
sponge. The true crepitant rale occurs only with inspiration, is feeble 
with the first rush of the air inward, and increases in distinctness and 
volume with a deep and forcible inspiration. Sounds closely resem- 
bling the true crepitant rale are that dry crackling which occurs in 
emphysema, the crepitation of oedema of the lungs, and that which 
marks the progress of resolution in cases of pneumonia and is called 
crepitation redux. But this last-mentioned form is larger, more of 
bubbling in character, and audible often with expiration as well as in- 
spiration. 

Suhcrepitant, mucous, and submucous rales are caused by the 
passage of air through tubes containing fluid. They differ in size, and 
somewhat in quality. The subcrepitant has a rather crackling charac- 
ter, similar to but larger than the crepitant, and occurring with both 
inspiration and expiration. The mucous and submucous have more of 
a bubbling or gurgling character, and are consequently larger and pro- 
duced in the larger bronchi, as the crepitant are formed in the minuter 
divisions of the bronchial tree. 

Again, certain rales are formed in connection with cavities, dilated 
bronchi, and cavity-like communications with the pleura. These take 
name accordingly, and are known as cavernous, amphoric, metallic 
tinlding, etc. 

Voic3-Sounds. — The sounds of the voice in speaking, coughing, 
and whispering are variously modified by disease. Vocal resonance 
may be wanting, or it may be modified or exaggerated. It is wanting 



PLEUEITIS. 



355 



when the lung has collapsed and lies against the spine, for example. 
The most important changes are those of exaggerated resonance. 
When the voice sounds clearly into the ear, as if coming from a bron- 
chus, when it should, by transmission through the lung-tissue, be much 
softened, it is called hronchophony. The transmission of sounds in a 
more intense degree, the voice apparently sounding directly into the 
ear from the chest, is entitled pectoriloquy. This modification of 
voice tone becomes more distinctive by whispering, and is then called 
whispering pectoriloquy. Still another variation of the voice-tone is 
that entitled mgophony. It has a bleating character, a vibratory, 
nasal tone which is imparted to the souild by a thin stratum of liquid 
interposed, and is therefore characteristic of pleuritis. 

Friction-Soimds. — These are, as a rule, to-and-fro sounds, synchro- 
nous with inspiration chiefly, and less with expiration, or in the prse- 
cordial region, with the cardiac movements. The sound varies in 
intensity from a mild rustling to a strong, harsh grating. The creal^:- 
ing-leather sound is apparently caused by the stretching of old, strong, 
and ligamentous adhesions, and hence is sometimes audible after the 
absorption of the liquid exudation of pleuritis. 

Succussion. — This is an extremely significant sign, as it can only 
be produced by the splashing of fluid in a cavity containing air or 
gas, and hence its value in chest affections. Succussion is effected 
by smartly shaking the patient from the shoulder. The splashing 
may be felt by the hand, or heard by the ear on the chest. 

The use and signiflcance of the foregoing signs and symptoms will 
be made apparent in the course of study of the various thoracic dis- 
eases. 

INFLAMMATION OF THE PLEURA— PLEURITIS. 

Definition. — Pleuritis, or pleurisy, is an inflammation of the pleu- 
ral membrane. Although not separable by any well-marked signs and 
symptoms, it is usual to consider two forms, acute and chronic. It 
may occur as an independent primary affection, or it may be secondary 
to some other disease. 

Causes. — There can be little doubt that many cases arise from ex- 
posure to cold, especially when a current of cold air is directed against 
the body in a perspiring state. There is probably a constitutional 
condition of some kind which determines the seizure, but this state can 
not be defined. It is more common in early life, up to the middle 
period, but is uncommon in old age. The secondary disease is much 
more frequently encountered than the primary. It is very frequently 
associated with pneumonia, by extension of inflammation through con- 
tiguity of tissue ; often, indeed, the pleuritis is the more important of 



* "Transactions of the Pathological Society," vol xxii, p. 108. 



356 



DISEASES OF THE RESPIRATORY ORGANS. 



the two affections. It is also associated with catarrhal pneumonia, with 
bronchitis, pericarditis, embolic pneumonia, pyaemia, abscesses, and 
other affections of the thoracic organs. It may be excited by caries 
of a rib, deep-seated (sub-pleural) abscesses, cysts and abscesses of the 
liver, etc. A dyscrasia may be a cause, when it is said the pleuritis 
is an intercurrent malady ; but it is now known that various morbific 
matters in the blood may excite serous inflammations, of which rheu- 
matism, gout, Bright's disease, cancer, diabetes, and the eruptive fe- 
vers may be taken as examples. 

Pathological Anatomy. — The initial lesion is hypergemia of the sub- 
serous connective tissue, while red points due to congested vessels are 
rather thickly scattered over the pleura. Such is the force of the blood- 
pressure that minute points of extravasation occur on the pleura and 
in the subserous tissue. The membrane has an arborescent or striated 
appearance, and is of a reddish or reddish-brown color. The injected 
portion of the membrane is dull, opaque, and rough ; the epithelium is 
swollen, cloudy, and granular, and is rapidly cast off, while the ad- 
herent cells undergo similar changes, and the subserous tissue becomes 
swollen, infiltrated, and crowded with migrated leucocytes. On the 
membrane there appears in detached masses, but rather thickly placed, 
an exudation which makes the surface rough and uneven. Large flakes 
of exudation may be thrown off, or the membrane may become thickly 
covered with a more or less heavy coating of fibrinous material. This 
may also contain a good deal of serous exudation in its meshes, when 
it presents a gelatinous, felt-like, or spongy appearance. If there be 
present much liquid, the flakes or masses of fibrin are seen floating in 
it, or they may be churned up with the serum and form a milky-look- 
ing fluid. The exudation which thus forms on the surface passes 
through various changes. It may undergo fatty metamorphosis, be- 
come emulsionized, and disappear by absorption, leaving the membrane 
unharmed. Adhesions may form by the gluing together of the op- 
posed surfaces, the connecting band of exudation undergoing organi- 
zation. The membranous exudation on the surface may also become 
organized ; large thin-walled vessels develop from the leucocytes, accord- 
ing to Rindfleisch, and close connections are formed between the neo- 
membrane and the pleura. Again, broad patches of membranous exuda- 
tion on the opposing surfaces of the pleura uniting by their margins, a 
central cavity is thus formed in which there may be serum, sanguino- 
lent serum, and flakes of exudation, etc., while close adhesions unite 
the pleural surfaces all around for a greater or less distance. These 
secondary cavities form at the base, on the lateral wall of the thorax, 
and between the pleura and pericardium, and, as they retain the effu- 
sion in a fixed position, give rise to errors of diagnosis. Those are 
examples of dry pleurisy, in which a very plastic exudation is thrown 
out on the two surfaces, over a small extent of the membrane, union 



PLEURITIS. 



357 



taking place, either directly or by a connecting band, there being no 
other exudation or effusion. It is probable that many of the exam- 
ples of connecting bands, or adhesions between the pleural surfaces, 
which are found post mortem, no symptoms having occurred during 
life, were of this character. Usually, however, in pleuritis, a more or 
less abundant exudation is poured out. According to the nature of the 
effusion, the cases of pleurisy are divided into the sero-fihrmous, the 
purulent, and the hcemorrhagic. 

In the sero-fihrinous form there is poured out from the distended 
vessels a quantity of fluid, straw-colored and having the qualitative 
composition of blood-serum. This contains floating in it masses of 
exudation or flakes, leucocytes, lymph, and red-blood corpuscles, which 
impart to it a more or less milky or sanguinolent character. The 
fibrinous part of the exudation consists of layers or folds of whitish, 
grayish, or reddish albuminous and fibrinous material deposited on the 
pleura. It may be soft, easily separated, or tough and elastic ; and 
may be readily detached from the membrane, or may adhere with 
considerable tenacity. When removed, this exudation is found to be 
closely adherent to a layer beneath, made up of the proliferating con- 
nective-tissue corpuscles of the basement membrane, together with 
a plastic matrix. These layers become ultimately closely connected 
by the growth of the connective-tissue membrane, or the fibrinous 
exudation may undergo fatty degeneration and be absorbed. The 
new connective-tissue membrane, built up as above described, is very 
rich in vessels, and readily unites with the same formation on the op- 
posing surface of the pleura. The corpuscular elements — leucocytes, 
lymph-corpuscles, cast-off epithelium, etc. — in the serous fluid may be 
so abundant as to give it a yellowish or purulent appearance. Hence 
it may be difficult to make a distinction between this and the truly 
purulent form, in which the serum contains such a quantity of pus- 
corpuscles that it is thick, yellowish, or greenish yellow. The term 
empyema is applied to a purulent collection in the thoracic cavity. 
Primary empyema is a very rare event, and, when it does exist, signifies 
the admission of air or some foreign matter to the cavity. The exuda- 
tion is at first sero -fibrinous, and becomes purulent, usually not until 
after the first week. There takes place, under conditions not now 
understood, a remarkable production of pus-cells — probably by enor- 
mously rapid proliferation of the leucocytes which have wandered 
from the vessels. While the serous fluid has an alkaline reaction, the 
purulent exudation is acid in reaction. Often the color of the exuda- 
tion is reddish from the presence of red-blood corpuscles in consider- 
able numbers. But this is not the hoemorrhagic exudation, properly. 
This consists of blood derived from the newly formed, thin-walled ves- 
sels of the exudation undergoing organization. A vessel giving way, 
the blood is poured out (or there is a diapedesis ^f the red globules) 



358 



DISEASES OF THE KESPIRATORY ORGANS. 



between the layers of the exudation and bursts through into the cavity 
of the pleura, and, mixing with the serum, forms a bloody fluid. The 
haemorrhagic form of pleuritis is usually tubercular in origin, or rather 
is due to the deposit of miliary tubercle exciting a recurring inflam- 
mation. An exudation may be hcemorrhagic when the pleuritis occurs 
in an individual having the haemorrhagic diathesis, or who is the sub- 
ject of purpura. 

The evil results of effusions are not limited to the affected mem- 
brane. When the quantity is sufticient to displace the neighboring 
organs, various functional disturbances arise from the compression. 
At first the lung retracts before the effusion, and only suffers by pres- 
sure when the effusion attains a certain volume sufticient to counter- 
balance its elasticity. As the fluid increases from below upward, the 
lung at first floats ; but gradually the expansibility declines, less and 
less air enters, and the organ is finally flattened against the spine about 
its roots. It then appears as a grayish, bluish, or reddish-gray, rather 
solid and flattened mass, about the size and shape of the adult hand 
without the fingers. It contains no air, is bloodless, and may be coated 
with a membranous exudation, or may be bound down by membranous 
bands. If adhesions exist, the lung will be compressed in part, or, 
if the organ is infiltrated by caseous or other deposits, the fluid will 
act on those j^arts that yet remain compressible. The fluid may be 
collected in secondary cavities, and compression be confined to those sit- 
uations. The blood being forced out of the lung, when the organ is 
flattened against the spine, distends the right cavities, which may dilate, 
and fills the sound lung, which may become congested and (Edematous. 
If the effusion occupies the right cavity, the heart is forced toward 
the left side, the diaphragm is pushed down, enlarging the capacity of 
the right thorax, and displacing the liver downward ; if the left cavity, 
the heart is forced over to the right, the diaphragm is pushed down 
to a less extent than on the right side, enlarging the left thorax, and 
displacing the spleen downward. The intercostal muscles become in- 
filtrated, weakened, and, yielding to the pressure, assume a convex 
instead of a concave shape, the thorax being globular and increased 
in circumferential and diametrical measurement. If absorption take 
place and the lung is not adherent, the air will again distend the alveoli, 
and the thorax assume its normal shape ; if the lung can expand again 
only in part, under the force of the atmospheric pressure, there will take 
place a depression of the ribs and distortion of the spine to efface the 
portion of the cavity which the lung can not fill. 

When there is present purulent or ichorous exudation in the thorax, 
the pleura will, if long exposed to its action, undergo necrosis, and 
a canal may be tunneled through the lung into a bronchus, and through 
this there may be more or less discharge, and a cure be ultimately 
effected. Caries of a rib may follow necrosis of a portion of the cos- 



PLEURITIS. 



359 



tal pleura, and a fistulous communication be opened up externally, the 
pus draining off, a cure being ultimately effected, or the prolonged 
suppuration may lead to tubercular deposit or to amyloid degeneration 
of the organs. A fatal peritonitis is in rare instances lighted up by 
the passage of ichorous matters through the agency of the lymphatics 
of the diaphragm. In other cases a fistulous communication is estab- 
lished, and the pus dissects downward along the psoas muscle, pointing 
under Poupart's ligament, or opens about the umbilicus, etc. Again, 
the pus may ulcerate into the mediastinum, into the pericardium, or 
into the great veins, but these are excessively rare accidents. 

Chronic pleurisy differs only in time and extent from the acute 
form. In pleuritis deformans the exudations are of great thickness 
and extent, and, by adhesion and subsequent contraction, extensive 
deformity of the lung may result. The space left between the ribs 
and the lung will be filled with fluid, and, as the pleura is damaged so 
that absorption can not take place, encapsulation may hold the fluid 
months, even years. Often, indeed, the false membrane which has 
become organized possesses the power of pus-forming (pyogenic mem- 
brane), fistulous communications are established, and matter is dis- 
charged for years even. The chest becomes greatly deformed by 
shrinking, the shoulder depressed, the spine curved, and the heart 
pushed aside and permanently fixed in its new position. 

Symptoms. — The symptomatology of pleurisy varies with the form. 
As dry pleurisy is the simplest form, it will be best to consider it first. 
This may set in with chilliness, fever, pain in the side, and dyspnoea, 
but more frequently there is little or no fever, no respiratory disturb- 
ance, only the pain in the side to indicate the nature of the attack. If 
the former symptoms are present, they do not continue longer than 
thirty-six to forty-eight hours ; if the latter, the symptoms rarely ne- 
cessitate confinement to bed. The physical signs of dry pleurisy are 
as follows : On inspection, the extent of the inspiratory movement is 
seen to be lessened by the pain — is arrested midway by a sudden start, 
and the body is curved a little to the affected side to avoid pressure 
on the inflamed membrane. On percussion, there is no change in the 
sonority from the normal minimum, because of the limited movement 
in inspiration, and if the pain is slight there will be no change in the 
normal maximum. On auscultation, the respiration will be feeble on 
the affected side, because of the pain elicited by the expansion in in- 
spiration ; and, if the pain is severe, the inspiratory murmur is rather 
suddenly arrested before completion, but if the pain is slight there 
will be no change in this respect. During the first two or three days, 
there will be audible on auscultation a sound due to the rubbing to- 
gether of the roughened surfaces of the pleura — a friction or to-and- 
fro rubbing sound — synchronous with the respiratory movements, and 
ceasing when they are arrested. If strong and loud, this friction- 



360 



DISEASES OF THE RESPIRATORY ORGANS. 



80und produces a vibration of the chest-walls, or fremitus, which is 
recognizable on palpation. Dry pleurisy terminates in two ways — by 
resolution, or by adhesion. When resolution takes place, the pain and 
fever subside, and the friction murmur gradually lessens, and finally 
disappears. At the apex, the friction murmur modifies into a leather- 
creaking sound, persists, and may be confounded with the crackling 
rales which accompany the first stage of tubercular deposition — a mis- 
take all the more likely, since pleuritic attacks are invited to the apex 
by the irritation of tubercle. Dry pleurisy occurs at the side and 
base of the thorax. This is the origin of the adhesions found after 
death, consisting of firm, strong bands of connective tissue, and which 
excited no symptoms that attracted attention. These bands often do 
serious mischief by limiting the movements of the lung. 

Acute pleurisy with effusion, the ordinary form, sets in as any 
other acute inflammation, with chill, general malaise, and fever, with 
pain in the side ; or there is in other cases, for several days, a daily 
paroxysm of fever, but without any local symptom for the first few 
days ; or, again, there are cases in which pain in the side and effusion 
have preceded the febrile movement. Less often than pneumonia is 
pleurisy announced by a decided chill ; more frequently there is chilli- 
ness recurring irregularly for the first few days. The fever which 
follows is a continued fever, with an evening exacerbation, and con- 
tinues up to the beginning of the effusion, or about eight days, with 
little variation. If there are rigors occurring every day, although 
irregularly, and persist, it is probable that the effusion is purulent, or 
that the pleuritis is tubercular. The type of fever is not peculiar to 
the disease, and is not therefore diagnostic ; the temperature does not 
often exceed 104° Fahr., and ranges from 101° to the former point. 
The pain is usually acute, lancinating, circumscribed, and is increased 
by breathing, coughing, or abrupt movements of the body. It is felt 
in the outer and inferior portion of the mammary region, sometimes 
at the base of the thorax, occasionally in the lumbar and iliac junction, 
and over a space which may be covered with a finger or two. It is 
commonly designated "a stitch in the side." Instead of being cir- 
cumscribed, it may be diffused and ill-defined. The duration of the 
pain is variable ; it may cease in three or four days ; it may reappear 
after having ceased for a time ; it may persist throughout the attack, 
and so long as it is present it affords evidence of the persistence of the 
inflammation. The severity and tenacity of the pain indicate the vio- 
lence of the disorder. Dyspnoea is also a prominent symptom in 
pleuritis. Several factors are concerned. When the pain is severe, 
the inspiration is suppressed, shallow, and frequent ; hffiraatosis is ac- 
cordingly impaired, and respiration is embarrassed from this cause. 
Fever, by increasing the waste of tissue and the excretion of carbonic 
acid, augments the necessity for oxygen. When effusion occurs, the 



PLEURITIS. 



361 



respiratory field is narroTved, and mechanical difficulties are created 
by the pressure. The decubitus of the patient is highly characteristic. 
Before effusion has taken place, the position on the sound side is 
easier, for, as Traube has pointed out, the blood gravitates from the 
diseased side, and thus relieves the nerves of pressui'e ; but, when the 
effusion begins to compress the lung, the position on the diseased side 
becomes the easier. AVhen there is extreme pressure, the patient can 
not lie down, and hence seeks rest in the semi-erect posture. More or 
less cough is present in pleuritis, and from the beginning. It is a sup- 
pressed cough, and is arrested in the act of inspiration by the catching 
pain in the side, and is again suddenly arrested in the explosion on ac- 
count of the pain given by the shock. When effusion comes on, the 
cough declines, but when there is considerable effusion cough is in- 
duced by the attempt to take a full inspiration, or by change of posi- 
tion. The ej:pectoration consists only of a little frothy mucus, unless 
bronchitis coexists, which is not unusual. As there are anorexia and 
more or less interference with digestion in all febrile diseases, the 
waste of tissue proceeds rapidly — on one side insufficient stipply, on 
the other increased oxidation. Emaciation, loss of strength, with the 
accompanying depression of the nervous system, are prominent among 
the objective symptoms in pletiritis. The countenance has an expres- 
sion of weariness, anxiety, and exhatistion, and may be pale or cya- 
nosed. The cyanosis is present if there is much orthopnoea ; but 
there may be more or less 23allor, possibly significant of hgemorrhagic 
pleuritis, especially if it occtuTed stiddenly. The urine is scanty, high- 
colored, has high specific gravity, and deposits urates abundantly. 

Although the rational symptoms of pleuritis are very significant, 
they are not so precise and definite as the physical signs. Having 
described the former, we will now take up the latter. On inspection, 
the movements of the affected side are seen to be restricted, to be sud- 
denly arrested, and with an expression of pain. When effusion is 
present, an enlarcrement of the affected side is discerned ; the inter- 
costal spaces are less concave, are elevated to a level of the ribs, even 
rise above them, and no movement takes place in respiration, while the 
healthy side is abnormally active. Ow palpation^ the absence of vocal 
fremitus is a very important and significant symptom. The fremitus 
of the voice is lessened as the effusion rises, to be entirely absent when 
the chest is distended. On the sound side the vocal fremitus is exag- 
gerated. When the effusion is large, on palpation there maybe fluctu- 
ation detected in thin subjects ; by tapping one side smartly, a wave 
traverses the liqind and is felt on the opposite side. The character of 

pjercussion-TiotQ is much affected by the quantity of liquid present. 
When there is a moderate amount of effusion, the tension of the lung 
is increased and consequently the note is high-pitched, rather hard, 
and having a distinct tympanitic quality. The tympanitic and high- 



362 



DISEASES OF THE RESPIRATORY ORGANS. 



pitch quality of the note is particularly evident on percussion of the 
infra-clavicular region, while the note becomes deeper and harder over 
the inferior and dependent parts where the effusion gravitates. So 
different are the pitch and quality of 
the percussion-note in the infra-cla- 
vicular region of the diseased and the 
healthy side, that, if the examination 
he carelessly made, the latter region, 
having none of the tympanitic quali- 
ty, will appear to be diseased. When 
the fluid accumulates so that the lung 
is covered by a layer of fluid, two 
inches in depth, the percussion-note 
will be dull all over the chest, except 
at the sterno-clavicular articulation, 
where the note will still be high- 
pitched and tympanitic, although 
somewhat dull. There will be abso- 
lute dullness over the whole of the 
affected side, except posteriorly over 
the root of the lung, when the cavity 
is full and the lung flattened against 

the spinal column. Exception should 27.-Limited Effusion and xnuchFibrln- 

also be made of a point correspond- ous Exudation. (DaCosta.) 

ing to the junction of the second rib with the sternum, where a tym- 
panitic note — le bruit de pot fele — indeed, is obtained by vibration of 
the column of air in the primary bronchus and trachea ; but in both 
situations a high pitch and hard quality are the characteristics, if the 
lung, is entirely flat provided the percussion be lightly made, so as not 
to develop the tympanitic quality obtained from the trachea and bron- 
chus. The value of the percussion-note is increased by the absence or 
presence of a sense of resistance. When there is fluid in the thorax, 
the sense of touch receives a different impression from that produced 
by the normal condition. The diagnosis of effusion in the left thoracic 
cavity is much facilitated by an attentive examination of the character 
of the dullness in the left hypochondrium. Owing to the shelving mar- 
gin of the lung, but especially to the proximity of the stomach and large 
intestine, the inferior portion of the left lung returns a rather higher 
pitched and tympanitic note on percussion than the portion above. 
This space is about two to three inches in width at the lateral border 
of the chest, narrowing to nothing at either extremity. When fluid 
forms, the diaphragm descends by pressure, and this space is gradually 
encroached on, and in the case of large effusion disappears. In the 
first stage of pleuritis the respiration is jerking, and on the affected 
side the lung is imperfectly filled with air. On auscultation these 




PLEURITIS. 



363 



characteristics of the breathing are ascertained — inspiration has a 
catching or jerking impulse, and hence the inspiratory vesicular mur- 
mur is feeble, because the lung can not be filled with air. When the 
membrane becomes rough, a rasping, grating murmur, audible with 
both inspiration and expiration — a to-and-fro friction murmur — is pro- 
duced ; it is synchronous with the respiratory movements and ceases 
when they are arrested. It may be so loud and strong as to produce 
a friction fremitus, and to be heard away from the chest-wall. It be- 
comes feeble as the effusion increases, and then disappears, to recur 
again for a short period after the fluid is absorbed. With the increase 
of the fluid in the chest, the vesicular murmur becomes more and 
more feeble and then ceases, and, w^hen it is no longer audible at the 
base, may be heard above the line of effusion and of dullness. When 
the lung is compressed but the bronchi are still permeable, and the 
body of fluid not too great, the breathing has the bronchial character, 
and has no vesicular quality. When the lung is flattened against the 
spine, no breathing-sounds of any kind remain. Similarly, hronchial 
voice, or hronchopho7iy, is audible from the still pervious bronchial 
tubes, as is the bronchial breathing, but this ceases as the correspond- 
ing breath-sound does, and no voice-sound remains, ^gophony, or 
goat's voice, is a modification of bronchial voice supposed at one time 
to be produced by the vibrations of a rather thin stratum of fluid, 
interposed between the chest-wall and the lung, but it is now regarded 
as a simple modification of broncophonyo With the disappearance of 
the effusion the lung expands, and there is a gradual diminution of the 
dullness, until the percussion-note becomes normal and the resistance 
declines correspondingly. The vocal fremitus is restored in the same 
order. The voice and breath sounds are at first bronchial, then gradu- 
ally become vesicular. As the bronchial voice and breath-sounds be- 
come audible, the friction-sound appears and continues up to the full 
restoration of the vesicular. Besides the friction to-and-fro sound, 
there are often heard, after the disappearance of the liquid effusion, 
coarse, creaking, grating sounds, which appear to be produced by the 
stretching of bands of adhesion, or the rubbing together of the large 
masses of solid exudation yet remaining for absorption. The author 
has witnessed the development and gradual disappearance of these 
sounds, during many months after recovery. Besides these sounds, 
rales, rather coarse, sub-mucous, and sub-crepitant, are audible during 
the process of absorption, and were supposed to be due to changes in 
the pulmonary parenchyma, but are now known to be produced by the 
opening up of tubes long compressed. Besides these, rales are present 
in cases of acute pleuritis, because of an accompanying bronchitis. 

Course, Duration, and Termination. — Pleurisy does not pursue a 
defined course, nor does it terminate in crisis, which is the normal 
mode for pneumonia, but under favorable circumstances the develop- 



364 



DISEASES OF THE RESPirwATOKY ORGANS. 



ment is gradual, and the return to health is by slow stages. Begin- 
ning in some one of the modes described, the fever regularly increases 
for the first four or five days, and then continues for eight or nine 
days pretty constantly at a uniform height. Then comes the period 
of effusion, when the temperature falls, the pain subsides, and the 
dyspnoea diminishes unless there is a large effusion, when the diffi- 
culty of breatbing is proportional to the amount of compression to 
which the lung is subjected. The length of the time the effusion 
continues at its maximum varies from one day to five. The absorp- 
tion may take place quite rapidly at first, but it does not continue at 
the same rate after the first two or three days. The reason is, prob- 
ably, because the liquid part of the exudation is more easily disposed 
of, the solid portion needing to undergo a fatty transformation to fit 
it for absorption. The rate of absorption is measured by the gradual 
return of the normal sounds, by the diminution of the dullness, and 
by the movement of displaced organs to their proper positions. The 
changes in the condition of the inflamed parts are represented in the 
improved appearance, better appetite, and increasing strength. A 
marked change takes place in the urinary secretion, which becomes 
more abundant, less highly colored, and contains for a brief period 
cast-off epithelium and a trace of albumen. The absorption of the 
last part of the exudation is exceedingly slow, and months, even a 
year or two, may elapse before the physical signs indicate complete 
restoration. The return toward health is often interrupted by fresh 
attacks of inflammation, by a new outpouring of effusion, by an acces- 
sion of fever and respiratory disturbance. Additional inflammation of 
the pleura and of the neo-membranes arrests the process of absorption, 
depresses the vital forces, and prepares the way to the chronic state, 
yet it sometimes happens that the new excitement awakens renewed 
activity in the process of absorption, which goes on more rapidly 
afterward. If, after the twenty-fifth to the thirtieth day, there is no 
appreciable diminution in the state of the effusion, the acute stage 
ends and the chronic begins. It maybe that the effusion remains 
stationary, and the general condition continues good ; in other cases 
grave symptoms may arise, the temperature may increase, and in a 
day or two attain to the maximum of the first two weeks, or pass 
beyond it ; rigors may occur irregularly, followed by paroxysms of 
fever and sweats ; the countenance becomes anxious ; the tongue dry ; 
the depression great — without there being any change in the extent 
of the effusion or any new complication. This grave change in the 
condition of the patient is due to the purulent transformation of the 
exudation. It has already been indicated that the exudation may be 
purulent from the beginning, and that under these circumstances the 
symptoms have at the outset the septicssmic character above described. 
The termination is in resolution ; in the chronic form ; in death. The 



PLEURITIS. 



365 



average duration of an acute, uncomplicated case is two to four weeks. 
Death may occur within the first two weeks, in the so-called fulminant 
form, or, when there is a very extensive sero-fibrinous efi^usion causing 
fatal syncope, most probably by compression of the great venous 
trunks, especially of the ascending vena cava, which may be twisted 
and its lumen obstructed by displacement of the heart. Again, oedema 
of the sound lung may suddenly ensue as a result of compression of 
its fellow, and cause death. An early recovery from pleuritis with 
effusion signifies that the effusion must have been of small extent. 
Any large inflammatory effusion, especially if the solid portion of it is 
considerable, must require a long time, months certainly, to dispose 
of it entu'ely. 

Chronic pleurisy is an outcome of the acute disease, or it occurs 
primarily. It differs from the acute merely in the severity and chro- 
nicity of the symptoms. The fever is slight, the pain is not severe, 
but yet extensive changes will take place in the pleura. When the 
characteristic anatomical alterations have been effected, there will be 
fever of the septicsemic type. The rational and physical signs are the 
same as those of the acute form. The duration of the cases varies 
from two or three months to several years. Attempts at absorption 
going on favorably may be stopped by a new inflammation of the 
pleura, and of the neo-membranes with more effusion. An effusion 
that has remained stationary for a long time may, unexpectedly, un- 
dergo absorption by reason of the development of vessels in the new 
formations. But a cure by absorption is rare ; there are usually incom- 
plete absorption, retraction and deformity of the chest, and permanent 
displacement of organs, or an external fistula, occurring spontaneously 
or resulting from an operation, may produce a favorable result com- 
paratively. Without the operation of paracentesis, chronic pleurisy 
usually proves fatal by tuberculosis, by purulent infection, or by pene- 
tration of the pus into neighboring cavities, etc. 

Complications. — The inflammation may extend by contiguity, and 
attack the pericardium — a not uncommon complication. There will 
occur a fibrino-serous exudation, often of considerable extent. The 
lung may be involved, but pneumonia is rather a coexisting disease — 
pleuro-pneumonia — than a complication. It is important to note that 
the lung on the sound side may be affected by oedema, a complication 
which adds immensely to the gravity of the case. Not only is the 
organ oedematous, but it usually presents patches of commencing pneu- 
monic infiltration. The importance of pleuritis as a cause of phthisis 
is hardly sufficiently recognized, in inducing tubercular deposit, and 
by adhesions limiting the movements of the organ, thus inviting dis- 
ease. 

Diagnosis. — The most important difficulties in diagnosis are expe- 
rienced in the differentiation of pleurisy with effusion from conditions 



366 



DISEASES OF THE EESPIRATORY ORGANS. 



in which the lung is solidified or is displaced by tumors, cysts, etc. 
Pleurisy is distinguished from croupous pneumonia by reference to 
the rational and physical signs. Pleurisy begins by chilliness, which 
persists for several days — pneumonia by a severe rigor, rarely two ; 
the pain in pleurisy is a stitch, a lancinating pain, which can be cov- 
ered by the finger — pneumonia by a sense of soreness and pain much 
more diffused ; the fever in pleurisy is continuous — in pneumonia there 
is a distinct crisis or lysis, somewhere from the fifth to the eleventh 
day ; the duration of pleurisy is indefinite — of pneumonia self -limited ; 
the expectoration in pleurisy is simply frothy mucus — of pneumonia, 
rusty or bloody ; in pleurisy the vocal fremitus is absent — in pneumo- 
nia it is not only present but exaggerated ; in pleurisy there is a fric- 
tion-sound, no crepitant rdle^ and the bronchophony is not so well 
defined — in pneumonia there is no friction-sound, the crepitant rale is 
present, and broncophony is loud and clear ; in pleuritis there is more 
decided dullness, the intercostal spaces are pushed out, the thorax en- 
iarged— in pneumonia the percussion-note is not so flat, the intercostal 
spaces and the size of the thorax remain normal ; in pleuritis the 
organs are displaced ; in pneumonia the relation of the organs is un- 
affected. Finally, the subsequent behavior of pneumonia and pleuritis 
leaves no room for doubt. An abscess of the liver pushing up the 
diaphragm, or an echinococcus-cyst growing in the same direction, of 
sufficient size to displace the lung in the same way, will cause the 
physical signs of an effusion into the thorax, and the diagnosis is pos- 
sible only by a careful study of the history, which is entirely different 
in the two affections. A tumor or cyst of the chest will produce dull- 
ness on percussion, displace organs, and, by compressing the lungs^ 
cause the disappearance of the voice and breath sounds. The differen- 
tiation is to be made by reference to the history of the cases, by the 
situation of the dullness toward or about the central and superior parts 
of the chest in tumor — the inferior part of the chest in effusion ; by 
the general and symmetrical bulging of the chest-walls in effusion, the 
circumscribed and irregular bulging caused by tumor ; by the absence 
of vocal fremitus in pleuritis — its exaggeration in cases of tumor. 

Although the withdrawal of the fluid is the only certain means of 
arriving at the nature of the effusion, there are signs by which we may 
approximate with considerable accuracy to a correct diagnosis. If, 
during the acute stage, the fever running high, the effusion pouring 
out rapidly, there suddenly ensue great pallor, weakness, and depressed 
temperature, followed after some hours by rise of temperature even 
higher than before, a haemorrhage has probably occurred ; or, if during 
the chronic stage there are recurrent attacks, and the above-described 
symptoms occur, the case is not only hgemorrhagic, but the underlying 
morbid process is tuberculosis. If the case is characterized from the be- 
ginning by repeated rigors, occurring irregularly, and followed by 



PLEURITIS. 



36r 



paroxysms of intense fever and sweats, the exudation is purulent ; if, 
during the course of an ordinary attack of sero-fibrinous pleuritis, the 
same septicsemic symptoms arise, the exudation has been transformed 
into the puruleut. 

Treatment. — The author wishes to protest at the outset against that 
revival in the belief of the aplastic power of mercury, and the return 
to its use in the treatment of serous inflammation, which is taking place 
in Germany, and finds expression in Ziemssea's " Cyclopaedia." ^ It has 
been definitely shown that, during the course of acute mercurialismus, 
an attack of pleuritis or inflammation of some serous membrane is apt 
to occur in consequence of morbific matters circulating in the blood. 
Unless it be established that this effect of mercury is substitutive, 
there is no ground for its employment, and certainly the experience of 
English and American physicians is opposed to the practice. 

As soon as the pleuritic inflammation begins, and the pain is a good 
indication, the patient should receive a full dose of quinine and mor- 
phine ( 3 j quinine and gr. ss. morphine for an adult), and the effect of this 
should be maintained by the repetition of smaller doses (gr. v quinine, 
^ gr. morphine) every four hours. If the stomach is irritable, the mor- 
phine can be administered subcutaneously, or, if the pain is very acute, 
this mode of administration is more effective than by the mouth. Be- 
sides the power of morphine to relieve pain, it is an effective remedy in 
serous inflammation. The combination which was so much employed 
formerly (calomel and opium) owed its virtues to the opium. If there 
be much fever — a strong pulse and elevated temperature — and the 
stomach not irritable, digitalis may be combined with the quinine and 
morphine — one grain every four hours. If the subject be plethoric, a 
dozen cups or leeches, drawing six ounces of blood, can be applied Avith 
advantage. The old plan of bleeding ad deliquu'/n animi, or until the 
pain ceased, was a powerful and certain means of relieving pain which 
has been rightly abandoned, but the local bloodletting is of service. 
Mustard-plasters and turpentine-stupes, as hot as can be borne, afford 
relief. The blood-pressure can be reduced also by active purgatives, of 
which the salines are best. When the exudation is poured out, a dif- 
ferent plan will be necessary. The only agents which possess the prop- 
erty of dissolving an exudation are the alkalies, and the most efiicient 
of these is ammonia. Carbonate of ammonia can be best given in a 
solution of the acetate (gr. v — x in | ss.— 3 j). They should take the 
place of the quinine and morphine. Absorption will be much aided by 
keeping up free outward osmosis through the intestinal mucous mem- 
brane by saline laxatives. The same process can be carried on through 
the skin by the usfe of jaborandi or its alkaloid, pilocarpine. This should 
be administered once or twice a day, but its action on the heart should 



Vol. xiv, p. 6S5, and elsewhere. 



368 



DISEASES OF THE RESPIRATORY ORGANS. 



not be forgotten, and care exercised if there be displacment of this 
organ, especially if there be a twist in the vena cava. The best mode 
of administering jaborandi is the hypodermatic injection of its alkaloid, 
pilocarpine — ^ of a grain of any of the salts. As the pouring out of 
so much fluid, the waste of tissue produced by a high temperature, 
and the interference with assimilation caused by the disordered diges- 
tion, rapidly impair the vital forces, it is important, by proper food- 
supply and the judicious use of stimulants, to obviate the asthenia. 
When, however, a large effusion exists, especially if purulent, it be- 
comes necessary to remove it by the operation of thoracentesis. Even 
if absorption may eventually succeed in disposing of the fluid, there is 
great danger that the lung will not be in a condition to expand again 
fully, and retraction and deformity of the chest will be the result. If 
the effusion be purulent, absorption can not take place, and hence 
thoracentesis is indispensable. The question of how early shall thora- 
centesis be performed has been much discussed. It ought not to be 
undertaken within a few days after effusion, nor unless the symptoms 
of compression are urgent while the exudation is going on. It ought 
not to be performed if the natural powers are equal to the task of re- 
moving the fluid early enough to save damage to the organs concerned. 
These rules apply to the sero-fibrinous form of pleuritis. Thoracentesis 
ought to be performed in the purulent form as soon as the nature of 
the case is evident, for nothing is to be gained by delay. The point 
of election when the choice may be made is underneath the inferior 
angle of the scapula, but the needle may be inserted at any place w^ith 
due regard to the position of the heart and great vessels. As regards 
the method of procedure, nothing has been added practically to the 
method of Bowditch (the real inventor of the aspirateur)^ which con- 
sists in exhausting the chest by the pump and attached needle. Al- 
though the admission of air does not seem to be very important, yet it 
is better to avoid it in cases of the sero-fibrinous, for, if subsequent 
operations are necessary, the effusion will become more and more pu- 
rulent. If this is the case, the tincture of iodine or a diluted com- 
pound solution can be injected with great advantage after removing the 
fluid (liq. iodinii comp. 3j — aquae 3 iv). This iodine injection is high- 
ly useful in empyema.* Precautions to avoid air are usually regarded 
as unnecessary in the case of purulent effusion. In those cases requir- 
ing repeated tapping, late experience has shown that the best results 
are obtained by establishing free drainage. If a suflicient opening for 
the drainage-tube can not be obtained in the intercostal space, exsec- 
tion of the rib is then necessary. The simplest of these operations 
should be performed with antiseptic precautions. If the pus of an 
empyema undergo decomposition and become foul, the cavity should 

* A warm solution of chlorate of potassa ( 3 j or 3 ij — 0 j) or of salicylic acid and 
boras ( 3 j of each to the 0 j), may also be used to wash out the cavity in empyema. 



HYDROTHORAX. 



369 



"be freely washed out with antiseptic precautions. Although the ad- 
mission of air in cases of empyema is not sought to be prevented, 
nevertheless the air should be deprived of its germs of putrefaction. 

As death has occurred several times very unexpectedly after the op- 
eration of thoracentesis, certain precautions are necessary. When the 
effusion is large, the whole amount should not be withdrawn at once, for 
the sudden removal of the pressure might induce a quick outpouring of 
fluid, or the great vessels, relieved of pressure, would overdistend the 
right cavities, or the heart, moving from its position, might cause com- 
pression of some of the vessels. Sudden death might very unexpectedly 
be caused by any of these accidents, notwithstanding the operation of 
thoracentesis is simple, not painful, and is otherwise free from danger. 
After the removal of the liquid exudation by absorption or by thoracen- 
tesis, a quantity of solid and semi-solid remains behind and is very 
slowly transformed. A succession of flying-blisters, painting with the 
tincture of iodine, and friction of the affected side with ointment of the 
red iodide of mercury, are the most effective external or topical appli- 
cations. The best results are obtained, not from the use of supposed 
stimulants of the absorbents, but from means to promote the nutrition. 
The iodide of iron (sirup), cod-liver oil, extract of malt, and a generous 
diet, the digestion stimulated by bitters and mineral acids, are the best 
means for increasing absorption. The amount of fluid taken should be 
reduced to the minimum ; for, although the restrictions imposed in a 
" dry diet " may be too rigid for ordinary patients, yet they can submit 
to a considerable reduction of the fluid. Absorption is promoted by 
lessening the water of the blood, which can be accomplished by saline 
laxatives and jaborandi. The laxatives should not be given so as to in- 
terfere with digestion, and a daily dose of jaborandi can be so admin- 
istered as not to interfere with the appetite or exercise. To procure 
complete distention of the lung, and to promote the oxygenation of the 
blood, compressed air should be inhaled daily, or a sojourn in an ele- 
vated, dry mountain-region should be enjoined. Although we may not 
agree with Dr. Leaming, of New York, and Dr. Andrew Clark, of Lon- 
don, in the importance of pleuritic exudations as a factor in phthisis, 
we must admit that they exercise some influence in initiating the pro- 
cess of fibroid degeneration and of tuberculosis. 

HYDROTHORAX— DROPSY OF THE CHEST. 

Definition. — By the term liydrothorax is intended an accumulation 
of watery fluid in the chest. It differs from pleuritis in the character 
of the fluid and in the state of the pleura. In pleuritis the effusion is 
an inflammatory exudation, and the pleura is the seat of an inflamma- 
tion ; in hydrothorax the fluid transudes— a merely physical process — 
and the pleura is unaffected except by maceration. 
26 



370 



DISEASES OF THE RESPIRATORY ORGANS. 



Causes. — The various conditions giving rise to general dropsy will 
cause hydrothorax — cardiac and renal diseases. Local obstruction to 
the course of the circulation produces pure hydrothorax, i. e., hydro- 
thorax not a part of a general dropsy. The most important of these 
local causes are emphysema and sclerosis of the lung, tumors so situ- 
ated as to compress the vena cava, vena azygos, the right auricle, etc. 
A general dyscrasia may induce hydrothorax, as Bright's disease, chronic 
malarial poisoning, etc. The most influential factor is the condition en- 
titled by the older authors latent pleurisy. In this malady there is a 
state of the pleural membrane closely allied to pleuritis — to that form 
known as dry pleurisy ; but instead of a plastic exudation there is an 
abundant outpouring of serum. 

Pathological Anatomy. — When the hydrothorax is due to any of 
the causes producing general dropsy, the effusion is bilateral, but usu- 
ally more abundant on one side. There will be found associated with 
the hydrothorax the anatomical changes in the lungs, heart, and kid- 
neys, proper to the particular form of dropsy. The fluid has a pale 
sea-green color, is transparent, and frequently coagulates on exposure 
to air, the coagulation consisting in the formation of an excessively fine 
reticulation of the minutest fibers. In the case of the so-called latent 
pleurisy the membrane is thickened, congested, and coated usually 
with a pellicular exudation, portions of which are, to a greater or less 
extent, floating in the fluid. The amount of serum present is from 
half a pint to two or three gallons. The effect of the fluid on the posi- 
tion of the heart and other organs is precisely the same as in pleuritis. 
The retraction of the lung and its subsequent compression also take 
place, as in pleurisy, except that it occurs more regularly. 

Symptoms. — In latent pleurisy, so called, there is some pain felt in 
various parts of the chest, but it is not acute and well defined as in 
pleurisy. It is usually situated in the side, and is a rather dull, ten- 
sive, heavy pain, or a feeling of soreness. It is increased by a full 
inspiration, or by coughing, but is not so severe as to interfere with 
daily duties ; and it is often transient, and makes so little impression 
on the mind as to be forgotten until attention is directed to it. There 
is some feverishness toward evening, but not much attention is paid to 
it, and hence it is usually overlooked. The cough may be rather trou- 
blesome, especially on lying down, but the expectoration is nothing 
more than frothy mucus. Often these symptoms pass unnoticed, and 
the first thing which attracts attention is an increasing difficulty of 
breathing. In the cases of hydrothorax pure, without pleural inflam- 
mation, there is no fever, nor pain in the side, and the first symptom 
referable to the thorax is difficulty of breathing greater than in pleu- 
risy, because the effusion is on both sides. In latent pleurisy, the left 
side of the thorax is involved in two thirds of the cases ; consequently 
the heart is pushed over to the right, and the semilunar space is oblit- 



PNEUMOTHORAX. 



erated. In hydrothorax there is no displacement of the organs, be- 
cause of the effusion on two sides and in the abdominal cavity. The 
physical signs are much the same in hydrothorax as in pleurisy ; but 
in the former there can not be that complete filling of the cavities, and 
hence there must be a considerable space of both lungs vrhere the voice 
and breath sounds remain unaffected. Furthermore, in hydrothorax, 
there being no limitation of the effusio n by neo-membrane and by ad- 
hesions, the fluid gravitates with the changes of position, and the area 
of dullness shifts accordingly. The course, duration, and termination 
of hydrothorax are those of the disease on which it depends. The 
formation of a large effusion in the chest adds to the severity of the 
case, and is not unfrequently a cause of death. This is especially true 
of dropsy, whether cardiac or renal. The hydrothorax is a source of 
extreme distress when it may not prove fatal, for the patient is unable 
to lie down, or to make any muscular effort without experiencing a 
suffocative attack. The author has witnessed a case of sudden death 
from hydrothorax in an aneurism of the arch of the aorta which was 
solidifying. The behavior of latent pleurisy is that of the sero-fibrin- 
ous form of acute pleurisy, when sufficient fluid has accumulated to 
produce symptoms by compression. 

Treatment. — If there is large effusion, delay is unsafe and thora- 
centesis should be promptly performed. As serum will flow through 
a fine capillary needle, but little pain and no danger attend the opera- 
tion of aspiration. If the effusion is not sufficient to produce distress 
by pressure, the treatment is directed to the condition on which the 
dropsy depends. The treatment for latent pleurisy is the same as for 
acute pleurisy with effusion. As the inflammatory symptoms are usu- 
ally overlooked, the physician is not consulted until the difficulty of 
breathing comes on, and then the sole question is, aspiration or not. 
The rules for guidance are the same as those already laid down. 

PNEUMOTHORAX— HYDROPNEUMOTHORAX. 

Definition. — The presence of air in the cavity of the thorax is 
called pneumothorax/ of air and fluid, liydropnetimotliorax. 

Causes. — Air or gas of any kind is rarely present in the cavity 
without liquid, and if air alone should enter an exudation would soon be 
excited. It is now settled that a serous membrane can not secrete air, 
and that, therefore, if air be found in the cavity of the pleura, it came 
there from without, or is a gas the product of decomposition or fer- 
mentation. Almost always it enters from without by perforation of 
the pleura, by the lung, or by the wall of the thorax. The most fre- 
quent mode of entrance of air is the giving way of a superficial cavity 
of the lung, tubercular or caseous. Very rarely the air passes through 
a communication made by a gangrene patch, or a hsemorrhagic infarc- 



372 



DISEASES OF THE RESPIRATORY ORGANS. 



tion, and still more rarely by the giving way of emphysematous alveoli. 
Abscesses of the liver ulcerating through the diaphragm may form a 
secondary purulent collection in the pleural cavity, which may com- 
municate through the lung with a bronchus, constituting pyopneumo- 
thorax. One of the modes of termination of a purulent pleuritis is by 
a fistulous passage to a bronchus, through which air is admitted to the 
pleura. Suppuration may occur in neighboring organs in a way to 
involve the pleura and some outlet, as — suppuration of bronchial 
glands, bursting into the pleura and ulcerating into a bronchus ; ab- 
scesses of the liver or of the kidney, perforating the diaphragm and 
the lung, etc. Traumatism is an important factor, pyopneumothorax 
being caused by penetrating wounds, incised or gunshot, the air enter- 
ing from without. 

Pathological Anatomy. — The accumulation of air in a given case 
is much influenced by the formation of the orifice of communication. 
If the entrance is easy and the exit difiicult, a very large amount of air 
may accumulate, and very often a sort of valvular arrangement, a 
fibrinous flap or plug, may exist at the orifice which has this effect. 
The lung quickly retracts until there is an equilibrium of the pressure; 
comi^ression is then exerted on it if the orifice is such that the air 
which entered without obstruction can not escape. The quantity of air 
which can be contained in the cavity depends on several conditions: 
on the compressibility of the lung, which may be slight owing to so- 
lidification by caseous or tubercular deposits ; the degree in which the 
other organs can be shoved aside ; the amount of liquid present, etc. 
It is a mixture of gases, not air, usually found in the cavity — of nitro- 
gen and carbonic acid, and but little oxygen, with some sulphuretted 
hydrogen if there be unhealthy pus present. If atmospheric air en- 
ters, the pleura infiames, and sero-purulent, then purulent exudation is 
poured out. As air contains the bacteria of decomposition, it is probable 
that their entrance is suflicient to excite purulent inflammation ; but, as, 
in pneumohydrothorax, ichorous, ulcerating, or decomposing materials 
pass in under the usual circumstances, these play a more active part in 
exciting inflammation than the air and its contained germs. The ex- 
udation which results from the action of these noxious matters is pu- 
rulent, often ichorous and bloody. The gas is contained in the space 
above the liquid, and the lung, having had the air squeezed out of it, 
lies flattened against the spine, unless old and firm adhesions resist the 
compressing forces. If there be much fluid, that side of the thorax 
will be enlarged, the intercostal spaces prominent, the diaphragm de- 
pressed, the heart pushed aside, etc. In some rare instances adhesions 
form in a circle between the two pleural surfaces, making a central 
cavity in which gas and fluid will accumulate to a large extent, a fistu- 
lous communication having been established with a bronchus. 

Symptoms. — Pneumothorax is to be studied in connection with the 



PNEUMOTHORAX. 



373 



diseases from which it arises. It may develop insidiously, so that it is 
discovered only on making physical examination of the chest. But, 
when a perforation occurs suddenly, pronounced, even formidable, 
symptoms are at once produced. Perforation may be announced by 
a condition almost of collapse, a temperature of 97° Fahr., and a small, 
weak, but very rapid pulse. If the temperature does not descend so 
low, the pulse is weak and rapid, and the respirations are hurried — the 
former reaching so high as 140, the latter up to 40, even 60. At the 
same time dyspnoea sets in with orthopnoea, and a severe pain, due 
either to sudden stretching of the pleura or tearing apart of adhesions. 
In other cases, for example phthisical subjects, none of these severe 
symptoms are produced, probably because narrowing of the respiratory 
field has been going on so long as to prepare them for this additional 
discomfort. The decubitus varies, the largest number seeking a posi- 
tion on the diseased side to permit the freest possible play of the 
healthy lung ; but a considerable proportion lie upon either side, al- 
though, when air first entered the cavity, orthopncea was experienced by 




Fig. 28.— Hydropneumothorax. 



most of the cases. The dyspnoea is due to several causes — to sudden 
compression of the lungs and the heart, and to a compensatory conges- 
tion, often with oedema of the other lung, whence the expiratory force 
is lessened and the voice weak and trembling. Cyanosis appears if 



374 



DISEASES OF THE RESPIRATORY ORGANS. 



there is much difficulty of breathing, the surface becomes cold and 
covered with a cold sweat, the tongue is blue and cold, and death soon 
closes the scene ; or, if life continues, general oedema supervenes from 
the venous stasis, while the arterial tension is low from ischaemia of the 
arteries. The lessening of the expiratory force makes the cough weak 
and ineffectual, and the expectoration diminishes. The low state of 
the arterial tension affects the urinary secretion, which is dense and 
red, with traces of albumen. The vocal fremitus may be present, di- 
minished, or absent, in pneumothorax — present when there are strong 
bands of adhesion which communicate the vibrations to the chest- 
walls ; diminished when the lung is not entirely collapsed ; absent 
when the cavity is distended with gas. On palpation, also, increased 
resistance will be noted while there is fluid, and increased tension with 
diminished resistance where there is gas. The percussion-note is char- 
acterized by its marked tympanitic quality, resonance, and elasticity. 
The resonance is not limited to the part containing air, but extends 
downward to the lower margin of the ribs, extinguishing the hepatic 
dullness in its usual limits, and the semi-lunar space on the left side, and 
also extends across to the middle of the sternum. A peculiar metallic 
echo may be developed on strong percussion. Percussion over the 
fluid produces the usual dull sound which sharply contrasts with the 
metallic clang of the percussion over air, and the dullness here varies 
with the position of the patient and follows the gravitation of the 
liquid. The character of the percussion-note is affected by several cir- 
cumstances : Avhen thick, false membrane lines the thoracic wall it 
acts as a damper, and there is much less of the tympanitic and metallic 
quality ; when an external opening exists, there will be produced the 
cracked-pot sound. On auscultation, there is no respiratory sound, ex- 
cept a modified, amphoric, blowing sound. All of the sounds audible 
in the chest — cough, rales, heart-beat, etc. — take on a distinct metallic 
quality. The dropping of fluid, or coughing, or movements of the 
body, produce under these circumstances metallic tinMing. But the 
most characteristic of the physical signs is succussion — a splashing of 
the liquid against the walls of the chest, produced by a sudden shake 
of the body. It is best heard by applying the ear to the chest, and 
then suddenly shaking the body by the hand placed on the patient's 
shoulder. The patient often recognizes this sound, and soon learns the 
best movement to produce it. It is like the splashing of liquid in a 
half-empty barrel. 

Course, Duration, and Termination. — The course of pneumothorax 
is much influenced by the associated lesions and the extent of the pul- 
monary insufficiency. If, already, the respiratory field is much nar- 
rowed, death may ensue in a few hours or days. Death is more fre- 
quently produced by the secondary pleuritis and its products, causing 
slow failure of respiration after some weeks. A cure is not to be ex- 
pected in cases, the most numerous, due to perforation of a superficially 



PNEUMOTHORAX. 



375 



placed cavity. Pneumothorax resulting from an incised wound in a 
healthy subject may get well after some weeks. A perforation occur- 
ring in the first stage of phthisis is not so important as one occurring 
later, and a cure is possible in the former before the constitutional 
forces are much depressed by the progress of the phthisis. A pneumo- 
thorax, produced by the discharge of a purulent pleuritis by a bronchus 
may get well after some months. It may be stated in general that the 
prognosis of pneumothorax is unfavorable, since very few cases get 
well even in the modified way of a permanent fistula. 

Diagnosis. — Pneumohydrothorax may be confounded with the 
large caverns of phthisis, with dilated bronchi, with emphysema, 
with pleuritis having limited effusion. Yomicse are confined to the 
upper part of the lung, have formed slowly without any sudden symp- 
toms ; they present amphoric sounds and metallic tinkling, rarely suc- 
cussion ; vocal fremitus is not lessened ; the chest-walls are retracted 
instead of distended, and the heart is not displaced. In pneumo- 
hydrothorax, loud, deep, tympanitic percussion-note is obtained all 
over the affected side ; the symptoms have occurred suddenly, and 
consist of severe pain, dyspnoea, and orthopnoea ; well-marked suc- 
cussion ; vocal fremitus lessened or absent ; the intercostal spaces 
bulging instead of retracted ; heart and other organs displaced. Em- 
physema is bilateral ; the respiratory murmur not absent ; bronchial 
rales audible all over the chest ; vocal fremitus present. Pneumo- 
hydrothorax is unilateral ; the respiratory murmur entirely absent, 
and all voice and breath sounds and rales from the affected side want- 
ing when the lung is collapsed ; vocal fremitus absent. In pleuritis, 
with effusion, the percussion-note has a tympanitic quality in the 
infra-clavicular region ; the dullness on percussion changes with the 
positions of the patient, and corresponds to the height of the liquid; 
an amphoric murmur is exceptionally audible over the root of the lung 
and at the summit ; with the increase of the distention of the chest, 
there is absolute dullness over the whole side ; no metallic tinkling, no 
succussion. In pneumohydrothorax, the percussion-note has a loud, 
ringing, tympanitic quality all over the chest, instead of a modified 
normal at the infra-clavicular region, and this tympanitic note is not 
supplanted by absolute dullness ; there are metallic tinkling and suc- 
cussion in perfection. 

Treatment. — As respects the condition* associated with pneumo- 
thorax and pneumohydrothorax, the treatment is indicated under the 
head of these maladies, and need not now be discussed. If there are 
much dyspnoea and danger of acute asphyxia, no time should be lost 
in making a free opening to permit the exit of air. The pyopneumo- 
thorax is to be treated by incision and the drainage-tube, and the use 
of antiseptic injections, of which iodine appears to the author to be 
the best. The severe pain requires the use of anodynes, unless the 
free exit of air procured by incision relieves the distress. The con- 



376 



•T 

DISEASES OF THE RESPIRATORY ORGANS. 



gestion and oedema of the sound lung may be relieved by ligatures to 
the thighs, by which a considerable quantity of venous blood can be 
retained in the lower limbs long enough to bridge over the period of 
danger. This expedient is preferable to bloodletting, which has been 
recommended for this purpose. 

PNEUMONIA— PNEUMONITIS— INFLAMMATION OF THE LUNG. 

Definition. — Pneumonia^ an acute inflammation involving the alveoli 
of the lungs, is designated by the German writers " croupous pneumo- 
nia," and by the French writers " fibrinous pneumonia." " Catarrhal 
pneumonia " differs from the fibrinous or croupous form in the seat and 
character of the inflammation. It attacks the capillary tubes imme- 
diately next the alveoli, and is a catarrhal instead of a croupous inflam- 
mation. The so-called lobular pneumonia is nothing more than catarrhal 
pneumonia, the changes in the lobules being secondary to the catarrhal 
process in the ultimate bronchi. Lobar pneumonia is a fibrinous or 
croupous pneumonia occupying and confined to a lobe. Pneumonia is 
also known in common language as lung-fever," " winter-fever," etc. 

Causes. — There is a growing belief that pneumonia is a constitu- 
tional or an infectious disease, like typhoid or relapsing fever. It differs 
from other inflammations in that it is self -limited, and terminates by 
crisis. It is a very common disease ; it occurs in all degrees of latitude, 
under every variety of climate, and at all ages. It is common in in- 
fants at the breast, but declines somewhat after the second year until 
after the second dentition, and is frequently encountered and is very 
fatal in the old. The male sex is most frequently attacked, because 
men are more exposed than women to those external conditions which 
tend to produce it. In-door life, a vitiated atmosphere, excesses, espe- 
cially alcoholic, and bad hygienic influences of every kind which induce 
debility, favor attacks of pneumonia. Certain seasons appear to invite 
the disease — those parts of the year characterized by humidity, high 
winds, and low temperature. In the British Islands winter is the 
season of greatest prevalence ; on the Continent, spring ; in this 
country, winter and spring, the former especially — hence the name 
winter-fever. Occasionally, pneumonia occurs in so many persons 
in a particular district that it may seem to be epidemic, but there 
are atmospheric influences at work to produce the disease, espe- 
cially excessive moisture conjoined with low temperature. It is a 
common belief that pneumonia is caused by exposure to cold, es- 
pecially to draughts when the body is warm and perspiring. That 
catarrhal pneumonia is induced in that way no one will dispute, but 
it is more than doubtful that croupous pneumonia is thus caused, 
unless there exist a predisposition to it, either of a vulnerable con- 
stitution or an inherited tendency to pulmonary disease. A phthisi- 
cal tendency, the author believes, is the chief factor, or that peculiar- 



PXEUMOXIA. 



377 



ity in the structure of the pulmonary tissue associated with consump- 
tion. There are other diathetic states concerned in the production 
of pneumonia — as gout, rheumatism, diabetes, the eruptive fevers, 
especially chronic alcoholism. Probably the real etiological factor is 
a microbe. Klebs ^ first made the attempt to define the pneumono- 
coccus, but the micrococcus of Friedlander has been more general- 
ly accepted as the true infective organism of croupous pneumonia, 
and this is active under the atmospherical conditions above men- 
tioned. 

Pathological Anatomy. — The state of the affected lung in pneumo- 
nia is usually divided into three stages, following the original descrip- 
tion of Laennec, based on the naked-eye appearances : engorgement ; 
red hepatization ; gray hepatization. The better arrangement, based 
on the description of Jaccoud, f but modified, is as follows : The stage 
of hyper (^mia, or engorgement ; the stage of exudation (red hepatiza- 
tion) ; the stage of resolution (degeneration and extrusion of the exu- 
dation) ; the stage of purulent transformation (gray hepatization). In 
the stage of hypersemia or engorgement, as now described, there are 
two distinct and separate acts — the increased blood-supply and the 
pouring out of an exudation. The lung has a reddish-brown appear- 
ance, is heavier, floats in water, but sinks lower than the normal lung- 
tissue, crepitates but little when pressed, and it is no longer elastic, but 
when an impression is made by the fingers it is retained. On section 
it presents a pretty uniform brownish-red tint, and it exudes a quantity 
of blood. On microscopic examination the blood-vessels are found to 
be distended with blood, and the capillary network surrounding the 
alveoli is so much enlarged that the alveoli are encroached on by 
it. \ The adjacent portions of the bronchioles are similarly en- 
gorged, the mucous membrane dark reddish from fullness of the ves- 
sels. This hypersBmia marks the first stage in the inflammatory pro- 
cess. The next step consists in the pouring out and coagulation of 
an exudation. There is exuded into the alveoli an albuminous or 
fibrinous fluid of great viscidity, and with it leucocytes which have 
wandered from the vessels, and red blood-globules present by diape- 
desis, and blood by the rupture of distended capillaries. This viscid 
albuminous fluid is poured out also into the bronchioles and bronchi of 
the inflamed section, and with it leucocytes and some red corpuscles. 
When the surfaces approximate, this adhesive fluid holds them tightly 
together until the incoming air separates them. In the capillaries of 
the inflamed area the blood-current is finally stopped, and the corpus- 
cles are then seen to be closely packed together and flattened at the 
points of contact. The albuminous or fluid exudation remains fluid 
for a short time, and then solidifies or coagulates, beginning in the 

* " Archiv fiir experiment. Pathologie u. Pharmacol," vol. iv, p. 1 JSYS. 

f " Traite de Pathologie Interne," vol. ii, p. 45. + Rindfleisch, op. cif. 



3Y8 



DISEASES OF THE RESPIRATORY ORGANS. 



alveoli and extending through the bronchioles outwardly. In coagu- 
lating it incloses the white and red corpuscles, and fills out the alveolus 
or bronchiole, probably expanding somewhat in the act of coagulation. 
When this process is completed, the inflamed part is solid, entirely 
without air, and falls immediately to the bottom when placed in a ves- 
sel of water ; it is also friable, is easily broken up between the fingers, 
and on section with the knife divides cleanly with well-defined mar- 
gins. The cut surface presents a reddish color, and is granulated ; 
this granular appearance being due to the little masses of coagulated 
exudation filling the cavity of the alveoli. These little masses may 
with some care be lifted out of the mold in which they are formed and 
held on the point of a pin. The tissue of the inflamed part, in respect 
to color, density, and granular appearance, so strongly resembles the 
cut surface of a section of the liver as to be called by Laennec red 
hepatization. 

There are two directions which the inflammatory process may now 
assume : toward resolution, or return to the normal state ; toward 
purulent transformation. As the first is the more usual, we describe 
first \hQ process of resolution. The albuminous material which had 
solidified undergoes liquefaction, and the pressure is thus removed 
from the surrounding vessels. The watery parts of the exudation dif- 
fuse into the vessels, and the solids, together with the cellular ele- 
ments, undergo a fatty degeneration, and are transformed into an 
emulsioned mixture without any of the viscidity of the original exu- 
dation, and capable either of absorption or of extrusion, much of it, 
doubtless, being expectorated. As the exudation liquefies, air again 
enters the alveoli, diffusion of oxygen into and of carbonic acid out 
of the blood is resumed, and the current of the circulation is fully 
reestablished. The effusion into the connective tissue between the 
alveoli and bronchioles is finally taken up, and the normal color and 
density are restored to the inflamed part, but its elasticity continues 
impaired for a long time. 

When tho, j^urulent transformation takes place, a change is wrought 
in the density,, color, and constitution of the inflamed area. It has 
been much discussed whether the epithelium of the alveoli undergoes 
any change, and contributes, by multiplication of its cells, to the exu- 
dation in croupous pneumonia, and whether any of the pus-corpuscles 
which become so abundant during the stage of gray hepatization or 
purulent transformation originate by proliferation of the epithelial 
cells. The former is denied by most authorities ; the latter is highly 
probable ; but the pus-cells are derived chiefly from the wandering 
white cells by multiplication and division. With the formation of 
pus-cells a process of fatty degeneration takes place in the albuminous 
exudation, but the rapid and exuberant formation of pus-cells is the 
principal event, the tissue being changed in color from the reddish- 
brown appearance of the red hepatization to the yellowish or grayish- 



PNEUMONIA. 



379 



yellow tint of gray hepatization. When such tissue is squeezed a 
little, a quantity of pus exudes, and the whole is easily broken up into 
a fatty and granular mass. ISot all parts of the inflamed area are 
equally advanced in suppuration, some parts still preserving the red- 
dish-brown, with here and there a patch of yellow ; and others uni- 
formly grayish-yellow, and some still advanced beyond this into a 
yellowish, almost diflluent mass. The stroma of the lungs yet remains 
intact, notwithstanding the enormous production of pus-cells. In rare 
cases a portion of the affected tissue proceeds beyond the stage of 
gray hepatization, or purulent transformation ; the stroma of the 
lungs yields, becomes disintegrated, and a small purulent collection 
is formed. A large abscess may be formed by the coalescence of 
several smaller ones. The collection may be bounded only by disin- 
tegrating lung-tissue, or the pus may be inclosed by a limiting mem- 
brane, or, in other words, become encysted. The author has seen a 
case of encysted abscess occupying a part of the middle of the right 
lung, which had existed for several months without symptoms. They 
may discharge by a bronchus, or into the pleura, or the pus of the 
encysted abscess may gradually undergo absorption. The termina- 
tion by gangrene is much more uncommon than that by abscess, and, 
when it does occur, signifies a most depraved state of the tissues. The 
passage of acute into chronic pneumonia is a comparatively frequent 
occurrence, when the disease is of diathetic origin, especially in stru- 
mous subjects, or wdien a tendency to pulmonary disease exists. 
When the change to the chronic form takes place, the process of retro- 
grade metamorphosis of the exudation preparatory to its extrusion is 
arrested ; the tissue appears compact, grayish, with here and there 
dark patches of pigment ; the hypersemia has ceased, and the infil- 
trated liquid is absorbed. In other cases the whole of the inflamed 
area does not pass over to the chronic stage ; resolution takes place 
more or less perfectly ; the exudation is disposed of in part, but still 
portions remain, more or less impairing the functions of the part. In 
other cases the products of inflammation are transformed into caseous 
matter. This change occurs when purulent transformation has taken 
place. The pus loses the fluid in which the corpuscles float, and these 
bodies become fatty, and more or less calcareous matter is mixed up 
with the fat, the ultimate product being a soft solid, looking like and 
having the consistence of cheese — whence the term caseous ^natter. 
It must be stated that this termination to croupous pneumonia is re- 
garded by the best modern authorities as very uncommon, while it is 
usual to catarrhal pneumonia. All parts of the lung are not equally 
susceptible to the pneumonic inflammation. The statistics show that 
the right lung is affected alone in one half of the cases, and as regards 
the left nearly twice as often, or, to express the relation more defi- 
nitely, using the statistics of Juergensen — the right lung was affected 
in 53'T per cent., the left lung in 38'23 per cent., both lungs in 8-07 



380 



DISEASES OF THE RESPIRATORY ORGANS. 



per cent. The inferior lobe of the right lung is the point of election, 
being the seat of inflammation in three fourths of the cases. There 
are certain consequences which follow on a pneumonia that ought not 
to be overlooked. When a considerable part of a lung suddenly 
ceases to functionate, there must be disturbances set up in its fellow. 
The obstruction to the pulmonary circulation induces over-distention 
of the right cavities and the veins, and ischaemia of the arteries. The 
blood displaced from the inflamed part, and which can not circulate 
through it, induces hypersemia and oedema of the other lung. 

Symptoms. — There are two modes of onset : in the less frequent 
there has been a day or two of bronchial catarrh and general malaise^ 
when some chilliness is experienced, pain is felt in the side, and the 
disease proceeds in its usual way. In the other and more frequent 
mode, a decided rigor is the initial symptom — a rigor more severe 
than in any diseases except malarial fever and pysemia. Elevation of 
temperature occurs at once, and by the evening of the first day has 
reached about 104° Fahr. In infants, instead of chill there may be 
a violent general convulsion or several of them. The duration of the 
cold stage is from a quarter of an hour to three or four hours, and dur- 
ing it the thermometer in the axilla notes some slight elevation of 
temperature, and in a few hours not only is the external temperature 
high, but the subjective sense of heat is grea't. The face is flushed, 
the eyes injected, there are intense headache, severe pains in the back, 
and muscular soreness in the members. The pulse is large in volume 
and strong in tension. There is usually a whitish-coated tongue, the 
appetite is wanting, and the stomach is nauseated, or there are attacks 
of vomiting on the first day. By the end of the first day, or the be- 
ginning of the second, there are rational symptoms which indicate the 
chest as the seat of the mischief. Pain in the side is experienced, and 
difliculty of breathing and cough now come on. The pain in the side 
varies in severity, and indeed is not always present. If the pleura is 
involved, the pain is more prompt and more acute ; if the deepest part 
of the lung, there may be no pain until the inflammation approaches 
the surface. The pain is most severe when it is first felt, and then it 
usually declines. The position of the pain is, as a rule, in the right 
chest, a little below and external to the nipple, but it may be felt in 
the lumbar region, in the iliac region, and in the shoulder. When 
pneumonia has attacked the summit of the lung, or as it occurs in the 
aged, pain may be absent. Coughing, breathing, especially a deep ex- 
piration, increase the pain. Accompanying the pain, or coming soon 
after it, is dyspnoea ; the respiratory acts are more frequent and shal- 
low, reaching as high as thirty or forty per minute, the shallowness being 
due to the pain caused by full breathing, and by the narrowing of the 
respiratory field. The flushed, anxious, and somewhat dusky counte- 
nance, the working of muscles of respiration merely accessory, and 



PNEUMONIA. 381 

those of the alse of the nose, make up an expression which has been 
called fades pneumonica. The cough, which appears on the first or 
second day, is very characteristic ; it is husky, suppressed, and painful. 
At first there is brought up a little frothy mucus, but on the third 
day there appear the sputa characteristic of this disease ; thick, viscid 
material like that which is poured out and coagulates in the alveoli 
and bronchioles of the lung. The sputum also contains blood-corpus- 
cles intimately incorporated with the viscid albuminous matter, but 
in varying proportion of coloring, from a light brick-red to a brownish- 
black. So tenacious and adhesive is the sputum that it remains adher- 
ent to the bottom of the vessel if turned over, and if a considerable 
quantity is collected in a vessel it presents a jelly-like appearance of con- 
sistency. The blood is not always mixed with the sputa at first, but 
the peculiar characteristics of the expectoration are in other respects 
present, the blood appearing in four or five days. In some debilitated 
subjects — for example, the subjects of chronic alcoholism — the expec- 
toration is thinner and more abundant, presenting an appearance like 
prune-juice, whence the name prune-juice expectoration — an ill-omen. 
Again, there may be no expectoration at all, which is sometimes the 
case in very adynamic states, and in pneumonia of the apex. There 
are also present in the sputa casts of the finer bronchi. The sputa 
should be agitated with water, and the grayish, undissolved particles 
should be fished out and then be put under the microscope. They are 

fibrous in structure, cylindrical, and 
branching. As has been stated, the 
maximum temperature is soon at- 
tained. On the evening of the first 
day it may reach 104" Fahr. (axil- 
lary), and for several days it con- 
tinues at about 103°, 104°, or even 
105°, there being a slight morning 
remission and evening exacerbation. 
The fever pursues this course with 
little variation in favorable cases, 
until the period of crisis, when just 
before the defervescence a rise may 
take place. This rise in temperature 
in anticipation of the crisis is usual 
but by no means invariable. The pulse during the stage of hyperse- 
mia is about 100 — full, hard, and strong ; but, as consolidation takes 
place, if extensive or extending widely, a change occurs in the pulse ; 
it becomes less full, and, when the ischaemia of the arterial side has 
reached the lowest point, the pulse is small, soft, and weak, and the 
superficial veins are abnormally full and prominent. The skin, during 
the time of greatest fever, is mordicant, or burning hot, and is dry or 




Fig. 29.— Fibrous Tissue in Sputa. (Beale.) 



382 



DISEASES OF THE RESPIRATORY ORGANS. 



covered with a warm perspiration. If the skin is relaxed, dusky, cool, 
and covered with a cold sweat, the condition is unfavorable. 

If the inflamed area is deeply situated and surrounded by healthy 
lung-tissue, the reactions produced on palpation and percussion are 
modified. On palpation the resistance is increased if the inflamed 
lung is exterior ; not affected, if within. The vocal fremitus is some- 
what increased. The sonority is diminished when the lung is con- 
solidated ; it is exaggerated when there is a layer of lung-tissue con- 
taining air overlying a consolidated area. Again, the sonority is 
exaggerated, or tympanitic, when in the beginning of the inflammation 
the lung still contains some air. The sound continues somewhat tym- 
panitic in quality about the consolidated portion of the lung at the 
maximum. With the progress of the exudation, and when the periph- 
eral portion of the lung is involved, there is greatly increased resist- 
ance, and the percussion-note over the inflamed area is flat, with still 
something of the tympanitic quality. The vesicular murmur becomes 
more and more feeble as the air less and less distends the alveoli. 
Within twenty-four to thirty-six hours there is heard, with or at the 
end of inspiration, a fine crackling sound over the region inflamed — 
the crepitant rale. This is wrongly said to be pathognomonic, since it 
occurs in acute tuberculosis, oedema of the lungs, etc. ; but it is highly 
significant in that it is audible in so few conditions, and occurs in 
pneumonia over a restricted area. This rale has been compared to the 
sound produced by rubbing a lock of hair between the fingers in front 
of the ear, to the burning of some grains of salt on live coals, but it is 
most perfectly imitated by the crackling made by India-rubber sponge 
when pressed and allowed to expand in front of the ear. As the sound 
is produced by the separation of the bronchioles and alveoli, adherent 
by the viscidity of the albuminous exudation, it is obvious that it can 
occur only during inspiration. When consolidation takes place, the 
crepitant rale ceases, but can be heard in the neighboring parts of 
the lung undergoing the sama process. Again, it becomes audible 
when the stage of resolution is reached. It is then known as crepitatio 
redux, but it then differs somewhat in quality, and is coarser and 
louder. The crepitant rale in children and old subjects is much like 
the crepitation redux. This rale is audible for a brief period only, 
during the stages of engorgement and exudation ; presently the vesic- 
ular murmur ceases altogether ; the respiration becomes sibilant, then 
blowing, and on the third day bronchial breathing and bronchial voice 
come on. The conductivity of the lung being increased by consolida- 
tion, the sound produced by the vibration of a column of air in the 
larger bronchi is communicated directly to the ear — whence the term 
bronchial breathing. The voice-sounds are communicated with equal 
distinctness to the ear from the larger bronchi — whence bronchial 
voioe. When the lung-tissue is consolidated, the disease is at its maxi- 



PXEUMOXIA. 



383 



mum ; there may be an extension of the area of inflammation in all 
directions, but the symptoms continue with uniform intensity for sev- 
eral days. AYe must now return to the rational symptoms and follow 
their development up to the period of crisis. The fever continues 
pretty uniformly at the point already mentioned, 102°, 103°, 104°, or 
105° — there being a morning remission of less than a degree. The pain 
in the side lessens or ceases altogether. The decubitus is toward the 
right with the body flexed, so as to relax the muscles of the affected 
side, and thus take the pressure off ; but the dyspnoea is less, because, 
the pain having declined, the respiration is free, but there is still 
some difficulty in respiration. The cough is more or less troublesome, 
and the characteristic rusty expectoration, or the more abundant 
"prune-juice," is brought up with every effort. Sometimes the ex- 
pectoration is hoemorrhagic, and several ounces may be discharged at 
a time. The smallness of the pulse and feebleness of the cardiac im- 
pulsion are due to ischaemia of the arterial side, as has been pointed 
out ; on the other hand, this state of the circulation may be largely 
due to depression of the forces. If the area involved in the inflamma- 
tion is not very large, the pulse may continue full and strong up to the 
crisis ; if this area is large and extending, then the fullness of the 
venous system and the emptiness of the arterial will have the effect 
just stated over the circulatory system ; consequently, the condition 
of the circulatory system will afford valuable information in respect 
to the extent of lung-tissue involved in inflammation. A rapid and 
weak pulse — 120, 130, 140 — irregularities in the rhythm, and unequal 
filling of the artery, are very ugly symptoms, denoting cardiac failure. 
Delirium is a result of the diminished arterial supply and the venous 
stasis of the brain ; there may be merely hallucinations or illusions, or 
noisy and violent delirium. Mental disturbance is more especially 
present in the cases of pneumonia occurring in drunkards ; delirium 
tremens too often masks so completely the pulmonary symptoms that 
they are overlooked. In such cases, the pneumonia is the disease, and 
the delirium tremens the symptom or complication, instead of the 
reverse. The obstruction at the lungs and the consequent venous 
stasis affect other organs besides the brain. The liver is congested, 
and jaundice, more or less decided, is present in many cases, whence 
the name bilious pneumonia. Again, the pneumonia of malarious 
regions is so often modified by malarial infection that the biliary dis- 
turbance may be either caused or increased by this influence. Fur- 
thermore, an accompanying gastro-duodenal catarrh may, by an exten- 
sion of the catarrhal process to the bile-ducts, set up a catarrhal jaun- 
dice. All of these influences coinciding, the biliary disturbance may 
enter largely into the symptomatology and therapeutics of the case. 
Very rarely a case of pneumonia may be complicated by acute yellow 
atrophy. The urinary secretion is altered in quantity and in compo- 



384 



DISEASES OF THE RESPIRATORY ORGANS. 



sition ; the quantity is reduced ; the urea and uric acid are increased, 
and the chlorides are much diminished or disappear entirely. The 
chlorides are diverted to the inflamed part and from the urine, so that 
the return of the chlorides (chloride of sodium chiefly) to the urine 
signifies the cessation of the inflammation. So sensitive is this indica- 
tion, that the return of the chlorides to the urine may precede for 
some hours the physical and rational signs which indicate the begin- 
ning of resolution. In consequence of the venous stasis, the hyper- 
£emia of the kidnej^s may induce albuminuria, and the urine may con- 
tain also cast-off epithelium of the tubules, but the albuminuria is a 
transient state. It should be noted also that, during albuminuria, 
pneumonia arises as a complication, and not unfrequently a fatal one. 

Pneumonia is one of the few diseases terminating by crisis. The 
critical phenomena consist in a sudden decline of temperature by crisis 
or lysis, and the occurrence of some special evacuation, as a large 
urinary discharge, a profuse diarrhoea, general sweating, an herpetic 



Day 



I or 

102° 
100° 
98° 
96^ 



¥4 



m 



10 



12 



Fig, 30.— Temperature of Uncomplicated Pneumonia of Eight Lung. Termination by Crisis. 

eruption, or considerable expectoration. The return in a few hours to 
the normal temperature or below it is the most conspicuous of these 
phenomena. As has been narrated, just before the defervescence, the 
temperature may rise higher than it had been, and the aspect of the 
case appear more formidable ; then the decline begins, and within 
twelve hours the normal or somewhat below is reached, or, if by 
lysis, the descent to normal occupies two or three days. The change 
thus wrought in the aspect of the patient is most remarkable. The 
countenance clears up, the difficulty of breathing subsides, the pulse 
falls to seventy, to sixty, even to forty per minute, and an herpetic 
eruption appears on the lips ; appetite returns, the skin is covered with 
warm perspriation, the urine increases in amount, the chlorides reap- 
pear, and the patient experiences an internal sense of well-being. The 
physical are in accord with these rational signs : moist sounds now ap- 
pear in the bronchical tubes, and the sputa become lighter in color, and 



PXEUMONIA. 



385 



an abundant expectoration of grayisli-yellow muco-pus takes the place 
of the rusty sputa ; crepitatio redud:, coarser than crepitatlo indudi^ ap- 
pears along the outer border of the consolidated area ; bronchophony 
is succeeded by a softer blowing sound ; the flatness is now dullness, 
with more of the tympanitic quality, and the vocal fremitus is less 
decided. Careful examination of the sputa during the stage of resolu- 
tion will disclose the presence of the fibrinous casts of the finer tubes, 
already described, and small masses, remains of the coagulated exuda- 
tion in the air-sacs. The alveoli are gradually opened up to the ad- 
mission of air, and under favorable circumstances the restoration of 
the lung is complete in a few days. In some unhealthy subjects, the 
victims of a diathesis, and sometimes those whose vital forces have 
been reduced by depressing treatment, repair is incomplete, and the 
affected part lapses into the chronic state. When the course is not 
toward crisis and health, there may be abortive attempts at crisis ; 
there may be some considerable subsidence of the temperature, an 
illusive appearance of a critical evacuation in the way of an exhausting 
diarrhoea, for example, but the natural powers are not equal to the 
effort ; there is no real improvement, the temperature rises even higher 



Day 



104° 
102° 

98° 
96° 



5? 



I 



10 



^4 



12 



13 



14 



15 



Fig. 31. — Temperature of Uncomplicated Pneumonia terminating by Lysis. 

than before, and all of the symptoms develop new severity. The pulse 
declines in strength and volume and becomes very frequent, the dysp- 
noea increases, and an adynamic state, in which the tongue is dry, 
the face cyanosed, the breathing quick and shallow, and the debility 
great, supervenes. If delirium had existed before, it now assumes 
more of the low-muttering character ; if it had not existed before, it 
is now apt to come on in the form of hallucinations ; there are increas- 



386 



DISEASES OF THE RESPIRATORY ORGANS. 



ing somnolence and a tendency to coma as the venous stasis and car- 
bonic-acid poisoning increase, and finally a condition of more or less 
profound coma ushers in death. 

Complications. — Pleurisy is a frequent complication, the two dis- 
eases occurring together in from ten to twenty per cent. A more 
acute pain and the usual signs of effusion are the only evidences of 
the existence of pleuro-pneumonia. The effusion must amount to six 
ounces to be detected with certainty (Juergensen). If there be exten- 
sive consolidation, the effusion must be proportionally small. Pleuritis 
is ascertainable with certainty only if there be sufficient effusion to 
displace the heart. The existence of pleuritis does not modify the 
course and behavior of the pneumonia itself, but the situation is ren- 
dered more grave by the simultaneous development of the two dis- 
eases. Capillary bronchitis is a very dangerous complication of croup- 
ous pneumonia, and may so conceal the latter as to appear as a case of 
catarrhal pneumonia. Emphysema is an occasional complication ; it 
should be stated, however, that pneumonia is an ordinary mode of ter- 
mination of emphysema. Pericarditis is more frequently a complica- 
tion of pleuritis, but it may also occur in the course of pneumonia. 
Granular degeneration of the heart-muscle occurs in pneumonia when 
the temperature is persistently high, and is a serious complication. 
The occurrence of jaundice has been alluded to as a symptom, and its 
mechanism explained. That pneumonia is a disease of great frequency 
and fatality in malarious regions is undoubted. Rheumatism and gout 
are also frequently associated with pneumonia, and to these may be 
added acute alcoholismus. Pneumonia of diathetic origin is severe or 
not according to the character of the diathesis ; it is very fatal in the 
alcoholic, but not more so than the uncomplicated malady in the rheu- 
matic or gouty form. The existence of a typhoid pneumonia is pretty 
generally admitted, but on questionable evidence. Pneumonia is an 
occasional complication of typhoid fever, but it is not a typhoid pneu- 
monia. This term is applied to a form of pneumonia occurring in the 
weak and debilitated, and has therefore a specially adynamic character. 
There is not the fever process which w^e designate typhoid ; there 
exists a pneumonia to which a specially adynamic character has been 
imparted by the depressed state of the vital forces. The term has 
been so far generalized that, in many places, every severe case of 
pneumonia is called typhoid pneumonia. 

Course, Duration, and Termination. — Croupous pneumonia is a well- 
defined, self-limited disease, which passes through its several stages 
with considerable uniformity. The stage of congestion or engorge- 
ment occupies the first twenty -four to thirty-six hours ; the stage of 
exudation or red hepatization — that period occupied by the pouring out 
and coagulation of the exudation — continues up to the crisis, which 
marks the beginning of the next stage. The crisis in pneumonia 



PNEUMONIA. 



387 



occurs somewhere from the fifth to the eleventh day of the disease, so 
that the exudation stage lasts from two to eleven days. The stage of 
resolution begins with the phenomena of the crisis, and lasts two to 
four days till convalescence is established. In rare cases (abortive 
forms) critical phenomena may occur even earlier than the fifth day. 
In the largest number the crisis begins on the seventh day, and, accord- 
ing to Traube, always on the odd days, reckoning from the day of the 
initial chill, but if we except the seventh day the statement of Traube 
must be denied. The stage of purulent transformation is not dis- 
tinctly separated from the stage of exudation or red hepatization, 
unless the occurrence of an abortive attempt at crisis fixes the period. 
It begins about the middle of the second week, and continues for 
several days to a week. The whole course of pneumonia is therefore 
comprehended within three weeks, but favorable cases may terminate 
in two weeks. The mortality from pneumonia has been and continues 
to be a subject of warm discussion on the part of those who advocate 
some special plan of treatment. Accuracy in diagnosis and skill in 
treatment are such uncertain elements in the statistics of mortality, 
under different plans of treatment, that but little reliance can be 
placed on the statistical method as applied to therapeutical questions. 
According to the most approved of the modern methods, the mortality 
ranges from five to twenty-five per cent. In determining a fatal re- 
sult in croupous pneumonia, so much depends on the condition of tha 
individual attacked, or the diathesis with which his system is tinctured, 
that no comparison of systems of treatment can be accurate that does 
not take note of them. Death is usually due to collapse — that is, car- 
diac failure, and obtunding of the nervous centers. This state is not 
necessarily caused by purulent transformation — it may be due to fail- 
ure of heart, and lungs, and brain, before the end of the stage of 
red hepatization. Death may be caused by the mere extent of the 
lesions in the lungs, inducing asphyxia ; these lesions consisting not 
only of localized pneumonia, but also of collateral hyperaemia and 
oedema. The effects of the pulmonary changes are enhanced by the 
stasis in the cerebral veins and ischaemia of the arteries, and by car- 
diac paresis. In subjects extremely delibitated, the tissues in a scor- 
butic state, the termination may be by gangrene, but this is extremely 
rare. The formation of an abscess is also rare, but is more common 
than gangrene. An example of encysted abscess which had been 
carried many months has been mentioned ; usually the abscess formed 
during the stage of gray hepatization terminates in a short time by 
discharge either into the pleural cavity or into a bronchus. The pres- 
ence of a quantity of the elastic tissue of the lungs in the sputa and the 
occurrence of repeated rigors and profuse sweats indicate the forma- 
tion of the abscess. If it become encysted, just as is the case in ab- 
scess in the liver or in the brain, the acute symptoms subside, the fever 



388 



DISEASES OF THE RESPIEATORY ORGANS. 



falls, the rigors and sweats cease, but yet some unfavorable symptoms 
continue — there are cough, fever, dry tongue, emaciation, and weak- 
ness, and the appropriate physical signs. In a variable period the 
abscess terminates in some of the modes already described. The ter- 
mination may be in the chronic form. There are then no critical 
phenomena ; the fever gradually diminishes, but does not cease ; the 
difficulty of breathing lessens, but there is more or less embarrassment 
on making any effort ; the cough also continues, and muco-^us and 
fibrous tissue are expectorated ; the weakness and emaciation do not 
improve if the decline does not go on^ and the physical signs of con- 
densation of the pulmonary tissue remain. The subsequent behavior 
is influenced by the local condition and the direction taken by the 
products of inflammation. There may ensue a gradual liquefaction of 
the exudation, its softening and extrusion may be effected without 
much damage to the pulmonary parenchyma, and after some months a 
cure be effected. On the other hand, the exudation may undergo casea- 
tion, with the usual history of pulmonary consumption. The caseation 
of the inflammatory products of croupous pneumonia is held to be 
doubtful by many, and is not regarded as common. The clinical his- 
tory is that of caseous pneumonia, and need not be discussed until that 
subject is reached. Finally, death may be caused by one of the com- 
plications, as pericarditis. 

Diagnosis. — Ordinary well-defined cases are recognized without 
difficulty ; it is the obscure or anomalous forms that occasion mis- 
take. Pleurisy w^ith effusion is very frequently confounded with 
pneumonia. They are differentiated by the following points : The 
onset of pneumonia is sudden, by a rigor, and followed by a high tem- 
perature — pleurisy begins more gradually, there is chilliness for a day 
or two, and the rise of temperature is gradual ; in pneumonia, the pain 
is rather dull, or a feeling of soreness diffused OA^er a considerable 
space — in pleurisy, a sharp stitch, which can be covered by a finger ; 
in pneumonia, there is audible, on inspiration only, a crackling sound, 
the crepitant rale — in pleurisy, the friction-sound, synchronous with 
the respiratory movements ; in pneumonia, the crepitant rdle is suc- 
ceeded by bronchophony, which continues — in pleurisy, when the effu- 
sion partly compresses the lung, a modified bronchophony, but, when the 
lung collapses, all voice and breath sounds cease ; in pneumonia, the 
dullness has a tympanitic quality, and is fixed in position — in pleurisy, 
the dullness is flat, and changes with the gravitation of the fluid ; in 
pneumonia, the organs retain their position — in pleurisy, the heart is 
pushed aside and the liver downward by the effusion ; pneumonia is 
self-limited, and terminates by crisis — these phenomena are wanting 
in pleurisy, the duration of which is indefinite ; subsequent to the 
crisis, the behavior of the two diseases is so different that further 
comparison is unnecessary. Next to pleuritis with effusion, pneu- 
monia is confounded with catarrhal pneumonia. They differ in onset 



PNEUMONIA. 



389 



— pneumonia sudden, with a rigor, and pain in the side — catarrhal 
pneumonia with an ordinary bronchitis, and a feeling of soreness 
rather than pain under the sternum ; pneumonia, as a rule, is unilat- 
eral, self -limited, terminating by crisis, or ceasing within three weeks 
— catarrhal pneumonia is bilateral, not limited nor terminating by 
crisis, and indefinite in duration ; if double, which is rare, pneumonia 
is limited to a portion of either lung, while catarrhal pneumonia is 
diffused over both. The differentiation of bronchitis and croupous 
pneumonia rests upon the same points. In respect to physical signs, 
the differences are marked : In pneumonia, the vocal fremitus is in- 
creased, and there is increased resistance on palpation — in bronchitis, 
the vocal fremitus is unaffected, and there is no change in the resist- 
ance ; in pneumonia, there is dullness on percussion — in bronchitis, 
the percussion-note is unaltered ; in pneimionia, on auscultation, there 
is audible the crepitant rale, which disappears and is replaced by bron- 
chophony — in bronchitis, there is no crepitant but a sub-crepitant rale, 
followed, not by bronchophony, but by sub-mucous and mucous rales. 
The rales in pneumonia or the bronchophony are audible at the seat 
of inflammation only — in bronchitis, they are diffused over the chest. 
An uncomplicated pneumonia differs from a pleuro-pneumonia in the 
following particulars : In pleuro-pneumonia there is more acute pain, 
a friction murmur as well as a crepitant rale, displacement of the 
heart and of other organs by the fluid, more absolute dullness on per- 
cussion, and less of the tympanitic quality to the percussion-note. 
Cases of pneumonia with cerebral symptoms may be mistaken for 
meningitis, but this can only happen should the chest not be exam- 
ined. In pneumonia of the aged, and, in some cases, in subjects of 
delirium tremens, there may be no cough or other rational symptom 
to direct attention to the chest. 

Treatment. — As we have to deal with a self -limited disease, which 
terminates by crisis between the fifth and the eighth day in sixty per 
cent, of the cases, and as we possess no specific, it is obviously our 
duty not to interfere too zealously in natural processes, and prevent, 
by our injudicious handling, a favorable termination. Furthermore, 
the so-called expectant plan, as pursued by moderns, is greatly more 
successful than the spoliative plan by bloodletting and tartar emetic, 
employed by the physicians of forty years ago. Cautious treatment is 
all the more necessary, since the diatheses are so largely concerned in 
the origin, the evolution, and the termination of this disease. The 
constitutional tendencies, the actual state, and the surrounding cir- 
cumstances should receive careful attention in deciding on a plan of 
treatment. A vigorous, healthy subject, free from constitutional vice, 
will require and bear a more vigorous handling than a broken-down 
alcoholic. If seen at the beginning, during the stage of congestion, 
the author believes that much may be accomplished in an ordinary 
case by a full dose of quinine and morphine (3]— gr. ss.), the appli- 



390 



DISEASES OF THE RESPIRATORY ORGANS. 



cation of cups or leeches, and small and frequently repeated doses of 
the tincture of aconite-root (two to five drops every two hours). At 
the same time a large mustard poultice should be put on the chest, 
and removed when the skin is reddened, to obtain its stimulant effect 
on the vaso-motor nerves within, and the feet should be immersed 
in a hot mustard foot-bath. When the quiniue and morphine have 
been absorbed, an active purgative should be administered, for this 
also serves to diminish the abnormal blood-pressure. If the viscid 
secretion is pouring out in the air-sacs and bronchioles, and coagu- 
lating, it is necessary to use some agent which possesses the power 
to lessen the viscidity and coagulation. Hughes Bennett employed 
the potassa salts (liquor potassii citratis) or an extemporaneous solu- 
tion of the bicarbonate, and his results were admirable. Ammonia, 
originally suggested by Richardson, has been latterly used more freely 
than potassa, and, as the author believes, with better results. Proba- 
bly the most advantageous method of administering it is the solu- 
tion of the carbonate in liquor ammonii acetatis ( § ss. — gr. v to x) 
every three or four hours. By the German school the muriate is 
preferred in corresponding doses, but it does not appear to the au- 
thor to be so useful. The ammonia solution should be continued up 
to the crisis. As soon as consolidation of the lung is accomplished, 
all arterial sedatives of every kind should be discontinued. The tinct- 
ure of aconite, or the more powerful tincture of veratrum viride, 
may be given with undoubtedly good effects during the stage of con- 
gestion, provided the subject is robust, but they cease to be useful 
when red hepatization has resulted, for then already arterial ischse- 
mia and overdistention of the veins exist — a state of things which 
can only be increased by cardiac sedatives. During this stage the 
temperature is high, and hence the necessity for measures to restrain 
it. Assuming that pneumonia is a specific disease, like typhoid, Juer- 
gensen maintains the necessity for the use of antipyretics, among 
which he places the cold bath first ; and the success of his treatment 
certainly seems to justify his theory. He demonstrates that there is 
no danger in putting a pneumonic patient in a bath, and that the re- 
duction of temperature by it exercises a favorable influence over the 
progress of the disease. Next to the bath quinine is most useful as an 
agent for reducing fever, but it must be given in scruple doses every 
four hours until the temperature falls to a proper point, when it 
may be suspended until the temperature rises again in twenty-four to 
thirty-six hours. The new antipyretic — antipyrin — has proved to be 
so certain and powerful a means of reducing febrile heat, that it 
may be resorted to in cases where the temperature approaches the 
condition of hyperpyrexia, or instead of quinine as suggested above 
for this purpose. To reduce the temperature, Juergensen regards 
as so important, that in the absence of the means for a cold bath 
he suggests exposing the patient naked to cold air. If there is 



PNEUMONIA. 



391 



much depression during this period (red hepatization), quinine may 
be given in stimulant doses (three grains every three hours), and 
alcoholic stimulants must be cautiously administered — half an ounce 
to an ounce of whisky or brandy every three hours. As the pe- 
riod of crisis approaches, the utmost circumspection is necessary ; 
the sudden defervescence and the occurrence of some exhausting 
discharge may tax too severely the vital powers. Suitable aliment, 
and appropriate stimulants, carefully administered, may then save 
life. 

The author feels it necessary to emphasize the evil effects of car- 
diac sedatives during the stage of exudation and of coagulation of 
the exudate. The administration of veratrum viride, digitalis, aconite, 
and tartar emetic, can only add to the burden of the heart, already 
laboring in consequence of the stasis on the venous side, and lack of 
blood on the arterial side. Paralysis of the heart is one of the most 
imminent dangers, because of this state. It is true that a continued 
high temperature contributes to bring about paralysis of the heart, 
but we possess the means of correcting this by the administration of 
quinine, and by cold baths or the cold wet pack. While arterial and 
cardiac sedatives are to be avoided at the stage of red hepatization, 
it is necessary also to avoid the immoderate use of alcoholic stimu- 
lants. These are needed, and in full doses in inebriates at the period 
of crisis, and when the stage of purulent transformation is reached 
if there are a rapid and weak pulse, a relaxed and clammy skin, and 
delirium. Protracted wakefulness and delirium need careful manage- 
ment. Opium or morphine must be avoided, owing to the state of 
» the pulmonary circulation, and the collateral hyperaemia and oedema. 
Then it is that chloral hydrate serves a most useful purpose ; it pro- 
cures sleep, quiets delirium, and has a good effect on the exudation. 
Care must be exercised, for large or frequently repeated doses may cause 
paralysis of the heart ; fifteen grains at night, with ten more in two 
or four hours, if the first dose is insufficient, is all that is required 
usually. Aliment must be carefully administered from the beginning, 
without waiting for depression to come on. Beef-juice, milk, egg- 
flip, wine-whey, chicken or mutton broth, etc., should be systematically 
administered every three hours. In weak subjects, a little wine may be 
given from the beginning. As already stated, the pneumonia of the 
inebriate requires alcoholic stimulants from the first symptom — for 
the delirium accompanying it is due largely to the sudden withdrawal 
of the supply, or the inability to retain it. Much has been said about 
the blistering-point in pneumonia. Counter-irritation is useful during 
the stage of congestion, as already indicated, but a fugitive counter- 
irritant, as a mustard-plaster, is all that can be properly used. When 
the crisis occurs, a blister is very useful. During the stage of red hepa- 
tization, turpentine-stupes, cotton wadding, or a flannel jacket, is use- 
ful unless the temperature is very high, when they do mischief. Fly- 



392 



DISEASES OF THE RESPIRATORY ORGANS. 



ing-blisters are serviceable in promoting absorption, wben resolution 
is imperfect and exudations still linger at the site of inflammation. 
To facilitate absorption in chronic, succeeding to acute pneumonia, 
the iodide of ammonium is highly beneficial. It may be administered 
with the iodide of iron, and in conjunction with the hypophosphites. 
If there are " prune-juice " expectoration, weak pulse, relaxed and 
sweating skin, turpentine in small doses, or eucalyptol, is extremely 
useful. During gray hepatization, they may be given for the double 
purpose of acting on the organ by which they are eliminated, and as 
cardiac stimulants. 

EMBOLIC PNEUMONIA— PNEUMONIA FROM EMBOLISM. 

Definition. — By embolic pneumonia is meant an infarction of the 
lung, due to embolic blocking of a vessel. 

Causes. — From the right cavities of the heart, or from some part 
of the venous system, an embolus is dislodged, and, entering the cur- 
rent of the blood, is deposited in a branch of the pulmonary artery. 
The circumstances under which clots form in the right cavities of 
the heart have been set forth elsewhere. 

Pathological Anatomy.* — The emboli which give rise to embolic 
pneumonia are of two kinds, simple or non-infective and infective. 
The former act in a merely mechanical manner by closing the vessels 
and preventing the passage of blood to the parts supplied by them ; 
the latter not only obstruct vessels like the former, but the infective 
material contained in them sets up a local infectious process. The 
size of the embolus, and consequently the capacity of the vessel ob-- 
structed, varies considerably, the resulting infarction being from a pea 
to a hen's-egg in size. If a simple embolus, the damage is confined to 
the area occupied by the infarction ; but, if an infective embolus, a sup- 
purative inflammation arises and an abscess is the result. To the for- 
mation of an infarction it is necessary that the embolus lodge in a 
terminal artery of Cohnheim — an artery without anastomoses — for, if 
the obstructed artery is connected by branches with others, the circu- 
lation in the obstructed area may be restored through collateral chan- 
nels. If the obstructed artery be a terminal one, as are those of the 
outer part of the lung in a restricted sense, the pressure in the veins 
causes a gradual filling of the obstructed vessels through the capilla- 
ries. Now, as the walls of these obstructed vessels are not properly 
nourished by the blood thus in a state of stasis, the blood diffuses 
through into the surrounding textures, which constitutes the infarction. 
Such an infarction is not often possible at the root of the lung, for here 
the anastomoses are too numerous, although they do sometimes occur ; 

* In the account of this process, Cohnheim's classical work, " Untersuchungen ueber 
die embolischen Processe," Berlin, 1872, Hirschwald, is followed. 



EMBOLIC PNEUMONIA. 



393 



but it is at tlie periphery that they usually form. As the vessels pro- 
ceeding from the root of the lung toward the periphery divide dichot- 
omously, it is obvious that, when an embolus obstructs one, the result- 
ing infarction must be wedge-shaped — the base of the wedge being 
toward the periphery of the lung, or outwardly. If a section be made 
through an infarction, its outline will be seen rather sharply defined, 
its color of a deep blood-red, and it will exude blood on slight pressure. 
If it has been formed for some time, its structure is denser from an 
infiltration of the alveoli, whence it presents a granular appearance ; 
it is dark-brownish in color, is drier, and exudes but little blood, and 
is very friable, easily breaking up into a pulverulent mass. The bronchi 
contain a frothy, bloody fluid. The tissue of the lung about the in- 
farction becomes hyper?emic and (Edematous. The pleura overlying 
it is deeply congested, or it may be inflamed and coated with a firmly 
adherent albuminous exudation, while the cavity contains more or less 
bloody serum. The infarction undergoes various changes ; the blood 
is gradually transformed, becomes fatty, and is absorbed, although 
patches of altered hsematin remain ; the proper tissue of the lung- 
undergoes atrophy, the connective tissue multiplies, and in this way a 
cure is effected, the luno; beino^ rendered useless to the extent of the 
infarction. In other cases an embolic abscess is produced, the embolus 
being infective ; but it does not have a wedge-shape ; it is globular, 
and presents the appearance of an ordinary purulent collection. In 
rare cases an infarction becomes gangrenous. Infarctions are found 
more frequently in the right lung. 

Symptoms. — As the embolus proceeds most frequently from the 
right side of the heart, the clinical history is that of some cardiac dis- 
ease ; but it may be produced in some distant part of the venous sys- 
tem under circumstances Avhich favor thrombosis. The prominence 
and urgency of the symptoms will depend on the size of the infarction. 
If it be small in extent, there may be no disturbance ; even if quite 
large, the symptoms may be masked by the coexistent disease. If a 
large branch of the pulmonary artery be suddenly closed, there will be 
acute dyspncBa of extreme severity, the patient will gasp for breath; 
become deeply cyanosed in a few minutes, and, may be, die at once. 
Sudden difiiculty of breathing is the most significant symptom at the 
time of lodgment of the embolus, especially if there is nothing in the 
condition of the heart to account for the dyspnoea. Fever comes on 
some days after the obstruction, but the rise of temperature is not very 
great. There may be chills, but they are not constant, except in the 
case of pyaemia. Bloody expectoration appears in a few days after the 
initial dyspnoea, and is usually inconsiderable in quantity. Besides 
blood, there is a viscid mucus which is the body of the sputa, and, as 
it adheres rather tenaciously, a good deal of coughing is necessary to 
bring it up. Pain begins with the implication of the pleura, and has 



394 



DISEASES OF THE RESPIRATORY ORGANS. 



tlie usual characteristics of pleuritic pain : it is acute and lancinating, 
and is increased by the movements of respiration. There are present 
the usual physical signs of consolidated lung — dullness on percussion, 
bronchial voice, and bronchial breathing. There may be a friction- 
sound due to the pleuritis, and also the evidences of effusion into the 
pleural cavity. It is obvious that the diagnosis of embolic pneumonia 
is difficult and uncertain. The sudden occurrence of dyspnoea, followed 
by bloody expectoration continuing eight or ten days, and the evi- 
dences of consolidation, are the only symptoms to indicate the real 
nature of the malady. If the history furnished the source of the em- 
bolus, the diagnosis would be proportionally facilitated. The prog- 
nosis is generally unfavorable, notwithstanding small infarctions may 
get well. There is no plan of treatment which can affect a mechanical 
condition of this kind, unless ammonia may dissolve an embolus. This 
should be tried. 

CATARRHAL PNEUMONIA. 

Definition. — Various terms have been applied to this disease, as 
capillary bro7ichitis, lobular pneumonia^ hronclio-pneumonia, etc. As 
right views with regard to it are necessary to a proper conception of 
pulmonary consumption, it is discussed here somewhat in advance of 
its proper position. By the term catarrhal pneumonia is meant a 
catarrhal inflammation involving the bronchioles and alveoli. It may 
be acute or chronic. 

Causes. — Catarrhal pneumonia may be an extension downward of a 
catarrhal process beginning in the bronchial tubes. It is probable that 
a catarrhal inflammation never begins, under any circumstances, in 
the alveoli. Typical examples of this disease occur during certain 
of the exanthemata, notably measles and whooping-cough. It is inti- 
mately associated with certain diatheses, as rickets and scrofula, and 
with structural alterations of the heart and lungs, as mitral lesions and 
emphysema. It is frequent in early life and in old age, and is less so 
at the period of greatest bodily vigor. Bad hygienic influences as to 
dress, habitations, humidity, and exposure, favor its development. Cli- 
mate is an important factor, and the period of most extreme variations 
is the period of greatest prevalence of this disease. 

Symptoms.— The acute form is the type ; the chronic differs from 
it merely in duration and severity of the symptoms. 

The initial symptoms are chilliness followed by fever, soreness of 
the chest, chiefly beneath the sternum, cough, and expectoration of a 
frothy mucus, and some difficulty of breathing. These symptoms in 
the acute form of the disease quickly develop into the more serious 
and characteristic proper to catarrh of the finer bronchial tubes. An 
abundant secretion, poured out all along the bronchial tree, must greatly 
affect the functions of the lungs. The breathing soon becomes rapid, 



CATARRHAL PNEUMONIA. 



395 



superficial, and labored, the accessory muscles of respiration are brought 
into play, and the alse of the nose work quickly and continuously ; the 
face is at first flushed and rather animated, and the eyes have a glaring 
expression, but the lips soon become bluish and cyanosis spreads over 
the face. The cough in the first onset is rather loud and bronchial, 
but, as the finer tubes become involved, it has more of a stridulous, 
husky character, and is often suppressed and partial because the difii- 
culty of breathing is too great to permit the necessary expansion of the 
chest. The cough is also painful, and in children is attended with 
moans and crying, and they make attempts to restrain it because of 
the soreness in the chest. The fever soon rises to the maximum of 
104° to 105°, and is nearly continuous, there being a slight morning 
remission. As the difticulty of breathing develops, there is increasing 
restlessness, never a moment of quiet, the struggle for breath and the 
search for an easier position being incessant. At first there are brief 
snatches of uneasy sleep, but, as the dyspnoea increases, a state of 
somnolence comes on which gradually deepens into coma, so profound 
at length that cough is suppressed. This somnolence is due to the 
deficient aeration of the blood and the accumulation of carbonic acid. 
Finally, the blood becomes wholly venous. Then the flush disappears 
from the face and is replaced by a death-like pallor, the cyanosis deep- 
ens about the lips, blue spots appear on the cheeks, and the superficial 
veins grow into thick black cords. The struggle for breath continu- 
ing, while the carbonic-acid poisoning increases, the most frantic but 
largely automatic efforts are made to remove supposed obstructions, 
and the patient, a child, may tear its skin about the neck and face with 
its nails, in the vain effort to remove them. On inspection, the cervi- 
cal and other muscles auxiliary are seen actively engaged, and a deep 
depression of the abdomen from retraction of the lower ribs is made 
with every strong inspiration. On palpation, the vocal fremitus will 
be unaffected during the first few days, but, when the lobules have 
collapsed in considerable numbers, the physical conditions are changed, 
and the vocal fremitus will then be increased. On auscultation, rales 
are abundant all over the chest ; they consist of sub-crepitant ra^es, 
which are somewhat coarser and louder than the crepitant, and are 
audible with both inspiration and expiration. With these also occur 
mucous and sub-mucous 7^dles, produced in the larger tubes. The 
respiratory murmur becomes more and more feeble as the condition 
of atelectasis is produced ; and, when a number of lobules are thus 
affected, over them the respiratory murmur ceases to be audible, a 
blowing sound is substituted, and this passes into bronchial breathing 
and bronchophony as the pulmonary tissue becomes consolidated. On 
percussion there is no change until the atelectasis occurs ; the sonority is 
diminished as the lobules collapse, until dullness is reached ; but the 
dullness has much of the tympanitic quality, owing to the proximit}^ of 



396 



DISEASES OF THE RESPIRATORY ORGANS. 



unobstructed alveoli. In making percussion in children, it is important 
to strike lightly, otherwise the primary bronchi and trachea will be 
thrown into vibration. The pulse-rate does not always correspond 
to the range of temperature ; it is usually higher. The pulse ranges 
from 140 to 200 or more in children, while in the aged it may be but 
little accelerated. Protracted high temperature may induce changes 
— parenchymatous degeneration of the cardiac muscle. If, therefore, 
during the course of this disease the pulse becomes feeble, irregular, 
and very rapid, the condition of the heart is one to arouse great solici- 
tude. The appetite is poor, vomiting often occurs, and diarrhoea is 
by no means infrequent. The embarrassment to breathing caused by 
the act of eating and swallowing induces young children to avoid eat- 
ing solid food, although they will often drink greedily. Cerebral 
symptoms are present to a greater or less extent in all cases : there 
may be headache, hallucinations, muscular twitchings, even convul- 
sions, and the coma of carbonic-acid poisoning. So closely do the 
nervous symptoms belonging to catarrhal pneumonia simulate those of 
tubercular meningitis that it may be exceedingly difficult to diagnos- 
ticate between them. In the chronic or, rather, subacute form of 
catarrhal pneumonia the development is slow, the fever of moderate 
intensity, and the difficulty of breathing not pronounced. If there 
has been an attack of acute bronchitis, or of whooping-cough with 
more or less extensive bronchitis, when the catarrhal pneumonia de- 
velops, the cough subsides, but the depression of the vital forces, the 
cyanosis, and the extreme emaciation, indicate the growth of the more 
serious lesions. When these cases tend toward a fatal termination, the 
grave symptoms just mentioned increase, and carbonic-acid poisoning 
comes on, death occurring in more or less profound coma. Some cases 
pursue a different course ; after a protracted subacute period in which 
the pulmonary lesions begin, an acute attack arises, and then the sub- 
sequent behavior is that of an ordinary acute case, death occurring in 
coma. When they tend to recovery, there is a gradual improvement 
in all the symptoms : the cyanosis diminishes, the dyspnoea lessens, 
the appetite improves, and gradually the general health is in part re- 
stored, the lungs imperfectly repaired. 

Pathological Anatomy— The changes involve the bronchial tubes 
and the lungs. The mucous membrane is the seat of an hypersemia 
from the larynx down, but it increases in severity downward, reaching 
the maximum at the most dependent part of the lungs. The vessels 
are so deeply injected that the mucous membrane is -a dark red, and at 
various points there are extravasations. The finer tubes are filled with 
a quantity of yellowish, creamy, purulent fluid. On section of the 
lung, drops of this exudation, escaping from the tubes, look just like 
pus escaping from a small abscess, especially if the divided tube has 
undergone dilatation — a change which takes place in the more pro- 



CATARRHAL PXEUMOXIA. 



397 



tracted cases. TMs pus is probably made up of the young cells de- 
rived by multiplication of tbe epithelium, but especially of the lymphoid 
cells which migrate from the vessels, and are found in the sub-mucoas 
connective tissue, in the alveoli, and in the bronchioles. There are 
two opinions now entertained in respect to the cellular elements which 
crowd the alveoli, and as to the part taken by the pavement epithelium. 
Among others, Rindfleisch maintains that these cells are produced by 
the multiplication of the epithelium, and derived in part from the pro- 
liferation of the lymphoid cells ; others, again, notably Buhl, deny the 
participation of the epithelium, and maintain that the products of the 
catarrhal inflammation are drawn into the alveoli by a species of suc- 
tion. Besides the changes in the mucous membrane, the bronchial 
tubes and intervening connective tissue take part. The bronchioles 
become dilated if they have been long subjected to the inflamma- 
tion, and the connective tissue undergoes hyperplasia, attaining to 
very considerable development. The formation of the very viscid 
exudation which takes place at the beginning of the process and the 
swelling of the mucous membrane are important elements in the col- 
lapse of the lobules (atelectasis) which is a conspicuous result in the 
sum of pathological changes. The collapse of the lobules takes place 
before the alveoli which form them are crowded with the products of 
the catarrhal inflammation. The mechanism of the collapse is about 
as follows : In the strong efforts in coughing or in expiration, or both, 
the air is forced out through the swollen tubes ; and, when the air has 
passed, the surfaces are brought into contact, and are made to adhere 
tenaciously. All of the residual air is gradually expelled in this way ; 
but, in the efforts at inspiration, the force is insufficient to separate the 
adherent surfaces, and, as the pressure is immediately increased in the 
adjacent lobules, the collapsed lobule is also compressed. The collapsed 
lobules are easily recognized by their appearance, which is of a dark- 
blue or purplish-blue color ; they are much firmer, do not crepitate, 
because they contain no air, and exude but little blood on section. 
The extent to which this process is carried varies in different cases. 
It begins in the most dependent part of the lungs, and advances for- 
ward and upward, involving much, sometimes the whole, of the lower 
lobe. In some chronic cases the process takes place chiefly in the 
upper lobes. Collapse of some lobules, the pressure continuing the 
same, necessarily involves the dilatation of others, and in this way 
emphysema results, the anterior portions of the lungs being affected 
chiefly. Attacks of catarrhal pneumonia in early life, imperfect repair 
only taking place, have much to do with the subsequent development 
of emphysema. After the lobules have collapsed, for a short period they 
continue permeable to air and may be inflated. The change in color 
and density which occurs when the collapse is effected is often mis- 
taken for inflammation — whence the term "lobular pneumonia." If 



398 



DISEASES OF THE RESPIRATORY ORGANS, 



the collapse continue, an inflammatory process is set up, similar to but 
not identical with that of croupous pneumonia, for it never becomes 
granular. The inflamed part becomes more solid, is of a dark-brown 
color, which terminates in grayish red ; it begins in the center of the 
lobules and spreads outwardly ; neighboring lobules affected in the 
same way coalesce, until ultimately a whole lobe may be involved. 
Then it presents to the eye, when the process is completed, a bluish- 
gray appearance ; on section it is found to be homogeneous, very firm, 
and tough. Before this final stage is completed it is very friable. 
The purulent matter in the bonchi and the catarrhal products in the 
alveoli undergo the cheesy transformation. The subsequent history 
is that of " caseous pneumonia." Those portions of the pleura in con- 
tact with the inflamed lobules become hypericmic, inflame, an exuda- 
tion is poured out, and adhesions form, or effusion takes place in the 
thoracic cavity. 'Not every case tends to death, or to the chronic 
changes above described. Partial recovery ensues in a considerable 
number, complete recovery in but few. When the collapsed lobules 
inflame, unless there be but few, restoration seems hardly possible 
even in the sense of a partly useless lung. If the lobules are capable 
of being distended again with air, and the catarrhal inflammation sub- 
sides in the bronchioles and alveoli, a cure is then possible. The 
purulent contents of the bronchi are brought up by coughing, and 
swallowed or expectorated ; the watery portion of the exudation in 
the alveoli is absorbed ; the cells disintegrate, become granular and 
fatty, and are ultimately absorbed — thus restoring the alveoli to the 
admission of air. The fluid and the cells of the intervening connec- 
tive tissue pass through the same process, and thus the injured part is 
restored, except that its elasticity continues impaired for a long time. 

Complications and Sequelse. — The complications are really parts of 
the malady in its entirety. Bronchitis is always present, and laryngitis 
frequently. Pleuritis is a necessary result when the peripheral portion 
of the lung is involved. The sequelae are very important. As was 
indicated under the head of pathological anatomy, there are two dis- 
eases which result from catarrhal pneumonia — emphysema and caseous 
pneumonia. The former is a result of the atelectasis or collapse of the 
lobules ; the latter is an outcome of the changes in the catarrhal prod- 
ucts which crowd the alveoli, in the bronchi themselves, and in the in- 
tervening connective tissue. In the account to be presently given of 
these diseases, the course of development from one to the other will be 
set forth. 

Course, Duration, and Termination. — The course of catarrhal pneu- 
monia is from a catarrh of the larger tubes to a catarrh involving the 
ultimate bronchioles, and probably the alveoli. There are two prin- 
cipal phases in the subsequent course : the development of the catar- 
rhal process ; the collapse of the lobules, and the transformations which 



CATARRHAL PNEUMONIA. 



399 



they undergo. Restoration may occur by a retrograde change in the 
catarrhal products and by absorption, and the collapsed lobules may be 
again expanded. Often the restoration is partial, and the lung maj 
remain contracted and atrophied at the site of the collapsed lobules. 
In still other cases the bronchial tubes are dilated, the connective tissue 
undergoes hyperplasia and thickening, the catarrhal products become 
caseous, and the collapsed lobules slowly inflame. It is obvious that 
the duration of such a malady must be subject to great variations. 
The simplest case of catarrhal pneumonia can hardly be concluded in 
a less time than two or three weeks. In fatal cases, death may occur 
in a day or two or within a week. In rapidly fatal cases death is due 
to such a blocking of the bronchioles that the blood can not be aerated, 
death occurring in deep coma from carbonic-acid poisoning. In chronic 
cases death occurs in two modes : by an acute exacerbation ; by grad- 
ual failure of the vital power, by the changes of catarrhal pneumonia, 
or the results of chronic inflammation in the collapsed lobules. In a 
large proportion of cases of catarrhal pneumonia in which recovery 
takes place, there is not a complete restoration, and hence the produc- 
tion of emphysema in after-years. 

Prognosis. — About one half of the cases of catarrhal pneumonia 
prove fatal. The prognosis must be guarded, not only as respects im- 
mediate mortality, but the future prospects of such patients. The 
more acute the attack the greater the danger of a fatal result, for 
acuteness in the attack means the collapse of many lobules, and the 
more extensive the area of disease, the more formidable the case in 
every aspect. The younger the subject the more dangerous an acute 
attack is, or indeed any attack of catarrhal pneumonia. Diatheses 
play an important part in the prognosis, for scrofulous and rachitic 
subjects are less able to bear up under the inflammation. The progno- 
sis is also much influenced by the bodily state, for the less the power 
of resistance the more severe the disease. 

Diagnosis. — Catarrhal pneumonia may be confounded with bron- 
chitis, croupous pneumonia, acute tuberculosis, and oedema of the 
lungs. From simple bronchitis, capillary bronchitis is separated by 
the size of the moist rales, by the dyspnoea in the one, its absence in 
the other ; by the signs of consolidation of the lung-tissue in the one, 
by the absence of such consolidation in the other ; and, finally, by 
the subsequent history so different in the two diseases. Croupous 
pneumonia is unilateral, or, when bilateral, limited to a certain area ; 
catarrhal pneumonia is bilateral and diffused over both lungs. Besides 
the difference in the physical signs recapitulated under the head of 
croupous pneumonia, there is the remarkable difference in the behavior, 
one being a self-limited disease, the other having no fixed duration. 
Acute tuberculosis at its onset is characterized by the presence of a 
capillary bronchitis, so that a differentiation is possible only by a study 



400 



DISEASES OF THE RESPIRATORY ORGANS. 



of the clinical history and course of the two affections. (Edema of the 
lungs is accompanied by similar symptoms as regards the dyspnoea and 
the physical signs ; but cedema is not a feverish state, and it is accom- 
panied by albuminuria or some evident cause. 

Treatment. — The chief source of danger in catarrhal pneumonia is 
the universal presence of a viscid secretion, which interferes with the 
entrance of air and thus prevents proper oxygenation of the blood, 
and causes collapse of the lobules, indirectly. The agents most useful 
to diminish the viscidity and favor the excretion of the exudation are 
the preparations of ammonia. The author has obtained the best results 
from the carbonate (three to six grains) and the iodide of ammonia 
(four to eight grains) in solution every two hours. The muriate has 
been much prescribed for the same purpose, but the iodide and carbon- 
ate are more efficient. These should be perseveringly administered. If 
the symptoms are subacute, the oil of turpentine, eucalyptol, and copaiba 
are very active in checking the formation and favoring the extrusion 
of the exudation in the tubes. Of these, probably copaiba is the best, 
as it may be more energetically pushed than the others. These stim- 
ulating expectorants, as they are called, owe their efficacy chiefly to 
the fact that the volatile oil which they contain is eliminated by the 
lungs and acts locally. They may be used in the acute cases also, 
after the subsidence of the most acute symptoms, and at the same 
time that the ammonia preparations are administered. If there be 
excessive dyspnoea, notwithstanding the use of these remedies, the 
accumulated muco-pus must be dislodged by emetics. Apomorphine is 
the most efficient of the emetics, and can be administered in the way 
to secure the best effects — by hypodermatic injection. Great care 
must be exercised in the use of this remedy, since occasionally pro- 
found narcotism is produced by it, probably due to the presence of 
morphine. The author has used the subsulphate of mercury, with 
most excellent effect, as an emetic in catarrhal pneumonia. Although 
this is a poisonous substance, no danger need be apprehended from it, 
since it comes up with the vomited matters. It can be given in from 
two to three grains at a dose, rubbed up with some sugar. Besides 
its emetic action, the subsulphate seems to have the power to check 
the formation of the muco-pus. The repetition of the emetic depends 
on the state of the case — every few hours it may be administered if 
the dyspnoea and the cyanosis require it. The immediate result 
of the emetic action ought to be an improvement in the breathing 
and lessening of the cyanosis. If the fever is great and the arte- 
rial tension high, good results are obtained from the combined use of 
tincture of aconite-root and tincture of belladonna — two drops of the 
former and one drop of the latter to a child of two years, every two 
hours. Continued high temperature demands the use of quinine and 
digitalis. To a child of two years three grains of quinine and one 
fourth of a grain of digitalis can be given morning, noon, and even- 



PHTHISIS PULMONALIS. 



401 



ing, until the temperature and pulse are brought within proper limits, 
when they should be administered at longer intervals. As this dis- 
ease makes enormous demands on the vital resources, the strength 
should be maintained by suitable nutrients from the beginning. Al- 
coholic stimulants are not only boriie well, but they are extremely 
serviceable, and seem to have power to check the exudation. Inhala- 
tions are highly useful. The air of the apartment should be kept 
moist by steam ; but, besides this, by means of the atomizer, there 
should be directed into the fauces a spray of solution of common salt, 
ammonium chloride, or potassic chlorate. If the spray can not be 
borne directly into the fauces, at least the atmosphere about the patient 
should be saturated with it. The air of the room may be filled with the 
vapor of oils of eucalyptus and turpentine, by heating them with water. 
These vapors have been found to be very efficacious. When there are 
much dyspnoea and cyanosis, the inhalation of oxygen gas is an ex- 
pedient of much value. In the subacute and chronic cases, excellent 
results are obtained from the persistent use of the iodide of ammo- 
nium, conjoined with the administration of the hypophosphites and 
lactophosphate of lime. Counter-irritation is useful in both acute and 
chronic cases. During the acute stage mustard-plasters and flying- 
blisters are serviceable, but the mistake should not be made of apply- 
ing deeply acting and prolonged counter-irritants, lest the irritability 
of the organic nei'vous system be exhausted, and the lesions within pro- 
moted. Turpentine-stupes, warm, are generally the most useful appli- 
cation. The tincture of iodine is adapted rather to the subacute and 
chronic than to the acute form. Among the occasional expedients 
employed in the treatment of catarrhal pneumonia is the inhalation of 
oxygen. This gives great relief to the dyspnoea, although it does not 
modify the morbid process in any way, and the relief is temporary. 
The author knows of no case in which the inhalations were continued 
for some time in such cases. The inhalation of turpentine-vapor might 
be carried on by disengaging the vapor in the apartment occupied by 
the patient. A local action of some value might thus be obtained, 
since it is apparent that the effect of this agent at the point of elimi- 
nation is the chief source of its utility when administered by the 
stomach. 



PHTHISIS PULMONALIS— PULMONARY CONSUMPTION. 

Forms of Phthisis. — From the point of view of the clinical history, 
three forms of phthisis may be admitted to exist : The phthisis of 
caseous pneumonia ; tubercular phthisis ; fibroid phthisis. As re- 
spects the essential nature of the malady, there is no difference, all 
these forms being characterized by the presence and development of 
the bacillus tuberculosis. The circumstances under which this organ- 
ism develops, the systemic state, and accidental conditions, determine 
28 



402 



DISEASES OF THE RESPIRATORY ORGANS. 



the particular form assumed by the morbid process. In the first case, 
the symptoms are of a more acute and inflammatory character, the 
products copious and cheesy in aspect ; in the second case, the phe- 
nomena are more immediately dependent on the presence and deposi- 
tion of tubercle ; in the third, changes (hyperplasia) in the connective 
tissue of the lungs succeed to bronchitis, pleuritis, etc. 

A special character is imparted to either of these forms of phthisis 
by such an etiological factor as the dust of certain occupations : for 
example, the " miner's lung^'' which is very common in the coal re- 
gions of Pennsylvania, and other mining localities. Grinders, potters, 
workers in dust of various kinds, suffer irritation of the lung tissues 
by the deposition of the fine, hard particles, which may be seen in situ, 
or be detected by microscopic examination, accompanied by less or 
more pigment. To the changes of phthisis are added these deposits, 
which color the lung in varying degrees, in some cases to a black tint. 
In these, as in all other forms of phthisis, the bacillus brings about 
the changes in structure characteristic of tubercular disease. 

1. CASEOUS PHTHISIS. 

Definition. — Caseous phthisis is that form of pulmonary consump- 
tion characterized by the caseation, or cheesy degeneration, of inflam- 
matory products in the lungs, and the subsequent softening and ex- 
trusion of the caseous matter, with greater or less destruction of the 
pulmonary tissue. 

Etiology. — The chief factor in the etiology of caseous phthisis is 
catarrhal pneumonia, especially of the apex, although it may be in any 
part of the lung. There must, however, be bodily conditions which 
favor the transformation of the catarrhal products, and the deposit 
and pullulation of the bacillus tuberculosis, since only a portion of the 
cases of catarrhal pneumonia undergo such transformation. These 
bodily conditions are a strumous constitution, or a state of lowered 
health, produced by the operation of various evil hygienic influences. 
The strumous or scrofulous diathesis is characterized by these pecul- 
iarities : a tendency to protracted suppuration and the production of 
a watery and ichorous pus, from slight injuries, and having little or 
no disposition to terminate, but rather to continue ; and the occur- 
rence of glandular enlargements. When in such a type of constitution 
a catarrhal process is set up in a part of the lungs, the products of 
such process, instead of undergoing resolution or some form of organi- 
zation, caseate or become transformed into caseous material, and this 
becomes a nidus for the development of the bacillus, or the growth of 
the bacillus brings about the caseation of the products of the catarrhal 
inflammation. We have in this fact an explanation of the frequent 
association of measles and consumption. Some of the cases affected 
to the same extent with catarrhal pneumonia get well, because there < 



PHTHISIS PULMONALIS. 



403 



is no underlying constitutional state to invite other diseases ; some 
pass into caseous pneumonia and phthisis, because they are tainted 
with the strumous diathesis ; in a small number acute miliary tubercu- 
losis develops. A strumous diathesis, not inherited, may be gradually 
acquired under the influence of bad hygiene — as living in a dark, 
damp, and foul habitation, with insufficient and improper food, and 
exhausted by overwork, anxiety, etc. If such influences are not suffi- 
cient to develop the strumous diathesis, at least they cause a bodily 
state in which caseation readily takes place in the inflammatory prod- 
ucts of catarrhal pneumonia. Caseous phthisis is comparatively com- 
mon in early life, because at this period measles, whooping-cough, and 
catarrhal pneumonia frequently occur. It may happen at any period, 
but is more common up to thirty-five than subsequently. As regards 
sex, the liability to this form of phthisis, it seems to the author, is 
greater in the female. 

Pathological Anatomy. — In the description of the pulmonary lesions 
of catarrhal pneumonia, it was shown that the alveoli of the lungs are 
crowded with cells, and that the branchioles are filled with yellowish 
muco-pus. The part which the epithelium of the alveoli takes in 
these changes is disputed. According to Rindfleisch this pavement 
epithelium undergoes desquamation and other changes. " The cells 
first become looser, their attached surfaces are covered with a thick 
layer of finely granular protoplasm ; at the same time in each cell the 
nucleus, which was before hardly visible, becomes swollen and is seg- 
mented. Thus are formed large granular epithelial cells, with rounded 
polygonal contours, and containing one or more nuclei." According 
to Buhl, the alveoli not containing a mucous membrane can not un- 
dergo the catarrhal process, and, therefore, the cells which so crowd 
the alveoli must be drawn or sucked into them. Besides the cellu- 
lar elements filling the bronchioles and alveoli, an enormous infil- 
tration of cells takes place into the intervening connective tissue — 
"many of them with two nuclei, nearly all with several surfaces, flat- 
tened." When this infiltration of cells has reached the point of dis- 
tending the septa between the alveoli, the vessels are so compressed 
that the circulation in them is suspended. Hyperplasia of the connect- 
ive tissue, although denied by Rindfleisch, does take place according 
to other investigators, and, in contracting, considerable shrinkage oc- 
curs, and a dense homogeneous mass results, made up of the distended 
alveoli, the infiltrated septa, the bronchioles dilated and filled with 
muco-pus and the contracting connective tissue, and is now in a condi- 
tion preparatory to the cheesy transformation. The caseous change 
consists in absorption of the watery parts, the fatty degeneration of 
the cellular elements, and granular disintegration of the fibrinous ma- 
terial, so that ultimately a soft solid is produced, yellowish in color, and 
having the appearance of cheese. In the mass are inclosed all the pul- 
monary elements — the acini, the bronchioles, the vessels, etc. " These 



404 



DISEASES OF THE RESPIRATORY ORGANS. 



nodules are surrounded by atelectatic, oedematous, or gelatinous paren- 
chyma in the preliminary stage of desquamative [catarrhal] pneumo- 
nia." The position of the catarrhal pneumonia resulting in the changes 
described is usually at the apex, but precisely the same alterations 





Fig. 32.— Caseous Pneumonia. (Thierfelder.) 



occur in other parts. They may result from a general catarrhal bron- 
chitis which has subsided elsewhere, but usually the disease is of the sub- 
acute form already described in the previous section, and limited, as it 
has a great tendency to be, to the apices or to an apex. Sometimes a 
whole lobe, a whole lung (phthisis florida), becomes infiltrated, and un- 
dergoes the cheesy degeneration. The softening in these cheesy nod- 
ules or masses begins in the center, and consists at first of a central 
cavity and softened canals extending from the center to the periphery. 
According to Rindfleisch, the cheesy masses in the lumina of the bronchi 
are the first to soften, while that in the peribronchial and perivascular 
spaces resists the softening process for some time. The force exerted 
in respiration, the dilatation of the bronchi, and the contraction of the 
parenchyma of the lungs, are the agencies which procure extrusion of 
the detritus. Larger cavities are formed by the breaking down of the 
divisions between smaller ones. The shape, size, conformation, and 
appearance of cavities vary with their age. The admission of air sets 
up putrefactive changes, and, instead of an odorless, softened caseous 
matter, it becomes a foul, greenish, or grumous matter. When this is 
mixed with the sputa, elastic fibers are detected in it, and the yellow- 
ish-gray solid particles containing the bacillus^ which are so character- 
istic a feature of the expectoration. At first, the interior of the cavity 
is irregular, rough, and is more or less full of disintegrating pulmonary 
tissue and projecting caseous material ; but, when all this is discharged, 
it is smooth, and lined with a connective-tissue membrane, which fur- 
nishes a quantity of purif orm fluid. If accumulation of the purulent con- 



PHTHISIS PULilOXALIS. 



405 



tents of the cavity takes place, putrid decomposition occurs, and the pus 
becomes fetid. Hjemorrhage may be produced by erosion of a branch of 
the pulmonary artery. This accident would be much more common, if 
it were not that the vessels are early closed and cease to be pervious. 
In rare cases the mischief is confined to one or a few localities ; extru- 
sion of the caseous matter occurs, there is no extension of the morbid 
process to neighboring tissue, contraction of the cavity takes place, and 
ultimately a mass of rather loose connective tissue remains to mark the 
site of the disease. This is the only mode of cure possible. 

Symptoms. — Caseous phthisis does not conform to one mode of 
onset. As respects the initial symptoms, there are three types — the 
chronic, the subacute, and the acute, or phthisis florida. In the chronic 
form, the onset is so gradual that the first symptoms can not be fixed 
on with certainty. A susceptibility to colds has been observed, and 
gradually a persistent cough and expectoration of muco-pus are com> 
plained of. Each severe cold is accompanied by chilliness, some fever, 
pains in the chest, loss of appetite, and a troublesome cough. During 
an attack of this kind there may be bloody expectoration, or a mouth- 
ful or two of coagulated blood may be brought up, or there may be a 
smart pulmonary hemorrhage. After such an attack it is observed that 
the "cold" does not get well ; that the cough and expectoration per- 
sist, that there are a daily morning chilliness, an evening fever, and a 
sweat some time during the night. A considerable loss of flesh is now 
observed, and there are great weakness and a feeling of exhaustion on 
slight exertion ; the appetite is poor, digestion is feeble, and, if a fe- 
male, the catamenia are becoming scanty. In the subacute variety the 
onset is not so gradual. There is a history of a severe cold, with pain 
in the chest, a considerable fever, a troublesome cough, and abundant 
expectoration. The attack is severe enough to require confinement to 
bed for a few days, and, although after a week or two some improve- 
ment slowly takes place, and the patient gets about again, the symptoms 
continue ; there are fever, some sweating at night, a persistent cough, 
pains in the chest, expectoration at first of frothy mucus, then of muco- 
pus ; emaciation goes on and the strength does not improve ; the 
appetite is indifferent. In a portion of these cases, after the catarrhal 
products have become caseous, there is a period of comparative repose, 
in which all the symptoms appear less severe. The cough lessens, the 
fever declines, the appetite improves, and a notable gain in flesh may 
ensue. Under such circumstances the patient, and physician also, mav 
feel greatly encouraged ; but none of the physical signs indicating 
consolidation of the caseous area change their significance, and the 
symptoms of improvement prove delusive. Presently the process of 
softening begins (after some weeks, even many months), and with the 
softening, destruction of the pulmonary parenchyma and the forma- 
tion of cavities. Caseous phthisis may come on in an apparently 
healthy individual — it may be in a robust subject, of a full habit. In 



406 



DISEASES OF THE RESPIRATORY ORGANS. 



a few months a marked decline in strength, flesh, and activity has oc- 
curred — all dating from the time of the acute cold (catarrhal pneu- 
monia), since which the symptoms of pulmonary trouble have persisted. 




Temperature of Catarrhal Pneumonia becoming caseous. — Phthisis Florida. 



In the acute variety, ov phthisis Jlorida, the whole course of the disease 
is run in a few weeks. It begins as a catarrhal pneumonia, involving 
almost the whole of one or parts of two lungs. It commences rather 
abruptly, with chilliness, fever, cough, pain in the chest, and rapid loss 
of strength. The temperature runs very high during the exacerbations, 
to 104°, 105° Fahr., or even higher, and there are considerable remis- 
sions and profuse and exhausting sweats. Owing to the sudden ob- 
struction of so much of the breathing-space, there is marked dyspnoea. 
The cough is very troublesome, preventing sleep, and the expectoration 
is profuse, purulent in character, and often streaked with blood or 
bloody, but has not the rusty appearance of the sputa of croupous 
pneumonia. The body emaciates rapidly, the strength is soon utterly 
gone, and the appetite is entirely absent. The symptoms increase in 
intensity, so that in the course of a few weeks or months the case ter- 
minates in death. Rarely a remission in all the symptoms takes place, 
an improvement in the local and general condition follows, and there- 
after the case pursues a more chronic form. In these cases of phthisis 
florida, a large part of one lung or parts of the two lungs are occu- 
pied with the catarrhal pneumonia, and the products of the inflamma- 
tion undergo caseous degeneration, so that after death a lung may be 
a mass of cheesy deposit. 



2. TUBERCULAR PHTHISIS. 

Definition. — Tubercular phthisis is that form of pulmonary con- 
sumption characterized by the deposit of gray tubercle ; by the changes 
due to such deposit, its softening and extrusion, and the less or greater 
destruction of the proper tissue of the lungs consequent on these pro- 



PHTHISIS PULMONALIS. 



407 



cesses. Tubercular deposit in these cases, if not limited to, is chiefly 
in the lung, and the disease of the lung-tissue quite overshadows that 
of any other organ. Acute tuberculosis is a general deposit of the 
miliary tubercle, accompanied by symptoms of universal disturbance 
of the functions of the body. As it is a general and not a local dis- 
ease, it is more appropriately considered with constitutional diseases. 

Etiology. — That tubercular consumption is an inherited malady, 
is held by most authorities. Although, by some leaders of modern 
medical thought, a certain peculiar " vulnerability of constitution " is 
transmitted and not the disposition to phthisis, the fact is undoubted 
that, when tuberculosis exists in a family line, it appears from one 
generation to another. This disposition to consumption is closely 
associated with scrofula or struma. In early life struma manifests 
itself by glandular enlargements, a tendency to protracted suppuration, 
and the development, under irritative conditions, of tubercle. After 
puberty, the tendency of the strumous constitution is to tubercular 
deposit in the lungs. One of the factors in determining tuberculosis 




Fig. 34.— Miliary Tuberculosis. (Thierfelder.) 

of the lungs is a badly formed thorax. The position at the apex, the 
favorite seat of tubercular deposit, may be due to the imperfect respi- 
ration at this point, owing to its position and conformation. All the 



408 



DISEASES OF THE RESPIRATORY ORGANS. 



coDditions which depress the bodily forces favor the growth and 
deposit of tubercle. Confined and foul air, excess of humidity, and 
rapid variations of temperature, are very influential elements in the 
sum of causes. Living and sleeping in badly ventilated apartments 
impair the quality of the blood, and invite disease to the lungs. A 
direct relation has been ascertained to exist between the amount of 
consumption in a given locality and the humidity of the air. Bow- 
ditch first ascertained this for Massachusetts, and the same fact was 
also shown in England. Variability of climate and rapid and extreme 
atmospherical vicissitudes have a most injurious effect on those hav- 
ing a tubercular diathesis. Elevation and dryness are as conspicu- 
ously beneficial as the opposite conditions are hurtful to those having 
a phthisical tendency.* The absence of sunlight, by contributing to 
anaemia, also favors the development of tuberculosis. Improper and 
insufficient food is an influential factor. The repugnance to fat, 
which is so often manifested by the phthisical, is unfortunate, since 
it is so necessary as a force-furnishing food. " Is phthisis communi- 
cable ? " is a question much disputed, but which seems supported by 
many affirmative examples. The first experiments with the inocu- 
lation of tubercle, by Yillemin, apparently proved its specificity, but 
subsequent researches rather diminished the confidence of those who 
adhered to this view, since it was shown that various kinds of animal 
and vegetable matter, especially when decomposing, produced the 
same results in certain animals when introduced under the skin or 
inserted into any of the tissues. It was soon maintained that it was 
the peculiar characteristic of the animal to produce tubercle on irri- 
tation, rather than the specificity of the tubercle-matter itself. Rab- 
bits and Guinea-pigs are the animals especially which were found to 
possess the peculiarity that tuberculosis develops when any form of 
suppuration is induced in them. It came to be held, then, that certain 
individuals are, in respect to the development of tuberculosis, like 
these animals : when subjected to suppurative inflammation, espe- 
cially in the glandular system, tuberculosis results. It is now main- 
tained, however, that there is nothing specially characteristic in the 
histological structure of miliary tubercle. There are nodules of syph- 
ilis, of lupus, etc., that can not be distinguished in respect to minute 
structure from the nodules of tuberculosis ; but the latter differ from 
the former in being specifically infectious. Thus, it has been clearly 
shown that general tuberculosis can be induced in animals by mixing 
tuberculous matter with the food eaten by them, and by causing them 
to inhale the sputa from tubercle-cavities. Probably the most con- 
clusive proof of the infectious nature of true tubercle is afforded by 

* See Lombard, " Traite de Climatologie Medicale," etc., tome iv, Paris, Bailliere et 
fils, 1880, p. 404, et seq. 



PHTHISIS PULMONALIS. 



409 



the inoculation of the cornea with tubercle-matter, and the production 
of general tuberculosis, when no other kind of matter effects such re- 
sults. This is, indeed, regarded by Cohnheim as the experimentum 
cruets — as proving beyond doubt the specific infective property of 
true tubercle. 

Such was the position of this subject when Koch's remarkable 
discovery was announced. By a special method of preparation and 
staining, he was able to demonstrate a specific bacillus — the Bacillns 
tuberculosis. This parasite has great vitality, and therefore easily 
resists ordinary destructive agencies. It is contained in the sputa, in 
the matter of cavities, in the giant-cells of tubercle, etc. The diag- 
nosis of obscure cases may depend on the recognition of this organ- 
ism. The number of bacilli is in direct ratio to the intensity of the 
destructive process, according to Balmer and Fraentzel [Berliner 
klinische Wochenschrift, No. 45, 1882). Hence, when the disease is 
slow or is stationary, the number of these bodies is small, and those 
present contain no spores. It appears, also, that if the bacilli are 
found in great numbers in the sputa, which is a favorite soil for their 
growth, they are less numerous in the walls of the cavities. If the 
fever is slight, the bacilli are imperfectly formed. N'ot only are they 
contained abundantly in the sputa, but also in the expired air of 
phthisical subjects. The presence of air is not necessary to their 
growth and development, for they exist in closed cavities of strumous 
and tubercular abscesses. The relation of these bacilli to tubercle is 
further shown in the fact that they have been found in various forms 
of tubercular ulceration, and in all parts, the seat of this process. 

Although the bacillus tuberculosis has been widely accepted, op- 
position is developing in various quarters. Especially has this oppo- 
sition to Koch's views taken form in Vienna, and hence something 
must be allowed to the jealousies which have existed between the two 
cities. Dr. Spina, who has long held the position of chief assistant 
to Strieker, may therefore be supposed to be fully acquainted with the 
technique of the processes. He opposes Koch at all points, and main- 
tains that the baciUus has not a constant form, but varies with the 
tissue and local condition ; that it is not essential to the tubercular 
process, and that it is frequently absent in undoubted tubercular dis- 
ease. From the practical side, Koch's theory has received a severe 
blow in two cases which have recently occurred at N^othnagel's clinic. 
In both tuberculosis was diagnosticated, because the bacilli were de- 
tected in the sputa. Yet, on post-mortem examination, both were 
ascertained to be examples of bronchiectasis, and no tubercles existed 
at any point. It follows, from these facts, that the parasitic nature of 
tubercular phthisis must be regarded as suh judice. The attitude of 
the reflecting physician should be that of receptivity, but he should not 
rush to the conclusion that the parasitic nature of phthisis is proved. 



410 



DISEASES OF THE RESPIRATORY ORGANS. 



Given a specific bacillus, tlie communicability of phthisis would 
thereby seem to be established. Before this discovery the evidence 
of its transmission, especially from husband to wife, had been accu- 
mulating. Indeed, a belief in the contagion has prevailed to a less or 
greater extent from the earliest times. In Southern Europe and in 
North Germany, especially during the last century, this belief was 
almost universal. In a treatise on consumption, by Dr. Morton, pub- 
lished in 1694, and in Dr. Young's work on the same malady, which 
appeared early in this century, this view was strongly maintained. 
In England, various writers have alluded to this subject, and by sev- 
eral of eminence the fact of the contagious nature of phthisis has been 
considered established by the clinical evidence. Thus, Dr. Walshe, 
who originally opposed the belief in its communicability, subsequently 
practically admitted it. In 1867 Dr. Budd published a paper in the 
"Lancet," in which he maintained that the disease is communicable, 
and that the tuberculous matter in the sputum contains the specific, 
infective material. Whether the bacillus of Koch continue or not to 
be regarded as the agent of infection, it must be admitted that strong 
reasons exist for adhering to the view of the contagious character of 
tuberculous phthisis. But, as every germ needs a special soil for its 
growth, so the specific infective material of consumption must fall 
into a properly prepared organism, to proceed to full development. 

If the bacillus tuberculosis is to be found in all suppurative 
inflammations of tubercular origin, we have in this fact an expla- 
nation of the occurrence of pulmonary tuberculosis as secondary to 
catarrhal pneumonia, to pleuritis, to glandular affections in various 
situations, etc. The conditions of its spread from a point where it 
first appears, the manner of its propagation from one individual to 
another, and the descent by inheritance, are points of which we have 
no certain knowledge. Especially is it difficult to reconcile the 
fact of heredity with the present knowledge of the behavior of the 
parasite. 

Pathological Anatomy. — The miliary tubercle is a grayish-white, 
translucent, and semi-solid granulation, about the size of a millet-seed, 
composed of a reticulum, with cells, giant-cells, and nuclei, the cells 
resembling white blood-corpuscles except that they are smaller, and 
the giant-cells having many nuclei. The reticulum is an extremely 
delicate network, inclosing the cells in its meshes, the giant-cells being 
placed nearly at the center of the granulation. The specific element 
is a minute, flat, long bacillus, rounded at its extremities, straight or 
curved, and beaded in appearance. Bacilli are usually single, but are 
sometimes found in pairs, and they multiply from spores, apparently 
only in the body, since they require a high temperature for their growth. 
They are found in the cells of tubercle nodules or masses, especially in 
the giant-cells. Tubercle, then, according to the bacilli theory, consists 



PHTHISIS PULMONALIS. 



411 



in the deposit and pullulation of the bacillus tuberculosis, and it is the 
matter thus formed which is deposited in the lungs, and constitutes 
pulmonary tuberculosis. According to Kindfleisch, tubercle takes its 
origin from the connective-tissue cells of the blood and lymph yessels, 
and the first deposits occur at the point where the bronchioles unite 
with the acini. (A group of acini communicating with a bronchus is 
a lobule.) A whitish nodule — a tubercle granulation — is thus formed 
around the termination of the bronchiole in the acini, in the angle at 
their point of junction, the deposit being in the connective tissue. 
The nutrient vessels are included in the granulation, and their adven- 
titia become swollen and infiltrated. It is this development of tubercle 
in the connective-tissue cells of the adventitia that weakens the vessel, 
and which may finally cause a rupture and haemorrhage. So many 
vessels at the apex are occluded by the mass of the deposits, that the 
pressure in the remaining vessels is much increased. When the walls 
of the vessels are infiltrated, rupture occurs the earlier by reason of 
the increased pressure from the cause just named. Tubercular deposi- 
tion also takes place abundantly in the bronchioles, not only those in 
immediate relation to the lobules, but for some distance beyond. The 
lymphatics distributed to the mucous membrane are infiltrated, and 
next those of the peribronchial space, so that all around the alveoli 
and bronchioles are thickly placed masses of tubercle granulations. 
The intervening connective tissue is also densely infiltrated. With 
the deposit of tubercle, there are associated the results of inflammation 
excited by the presence of these granulations. According to Kind- 
fleisch, a desquamative pneumonia plays an important part in the subse- 
quent changes. The cheesy transformation of the products of catarrhal 
pneumonia, atelectasis, bronchial dilatation, assist materially in enlarg- 
ing the area of structural changes. The masses of miliary tubercle, in 
a variable period after their deposition, and often within a few weeks, 
undergo a cheesy transformation, by which they are brought into close 
resemblance to the cheesy products of caseous pnuemonia. It is a 
process of fatty degeneration, beginning in the central portion of each 
nodule. In acute tuberculosis, to be studied hereafter, the gray granu- 
lation is disseminated throughout both lungs. In the pulmonary tuber- 
culosis, the deposits occur chiefly in the superior lobes, and are often 
limited to the apex, but are very rarely indeed confined to one lung, and, 
when this is the case, the left is more often attacked than the right. 
When the process of cheesy transformation is completed, the resulting 
mass is opaque, yellowish, and has the friability of cheese. The infiltra- 
tion of all the parts, ultimately, of which the parenchyma of the lungs is 
composed, the closure of the vessels and entire arrest of the nutritive 
supply, and the compression exerted by the contracting connective tis- 
sue, necessarily cause a necrosis of the pulmonary elements. When 
the stage of softening comes on, the products, although having a puri- 



412 



DISEASES OF THE RESPIRATORY ORGANS. 



form appearance, are not purulent. Inflammation and suj^puration are 
excited in the tissues, with the necessary result of disintegration. On 
the surface of the mucous membrane the destruction of the tissue in 
and about the site of the tubercle granulations is an ulceration ; in the 
mass of disease in the body of the lung the destruction of tissue pro- 
duces a cavity. The fluid matter resulting from the softening of the 
yellow tubercle is homogeneous, of the consistence of cream, and hav- 
ing a greenish-yellow or grayish color. Mixed with it are necrosed 
pulmonary elements, solid particles of a yellowish color, and the whole 
is contained in a small cavity, surrounded by masses of cheesy tubercle. 
The softening proceeds from the center to the periphery, and in its 
progress the pulmonary elements are disintegrated with it. When 
discharge of a cavern takes place by the ulceration opening a bronchus, 
or, according to Rindfleisch, by the tubercular ulceration of a bronchus, 
the elastic fibrous tissue may be recognized in the sputa. Large cav- 
erns are formed by the breaking down of the intervening septa and 
the coalescence of smaller ones. The increase in the area of destructive 
ulceration is greatly promoted by the attacks of catarrhal (desquama- 
tive) pneumonia, which induce softening and dilatation of the bronchi, 
and collapse of lobules (atelectasis) ; and catarrhal products fill the alve- 
oli and bronchi, and there caseate. Cavities are produced under these 
circumstances by the softening and extrusion of the caseous masses as 
described under the head of caseous phthisis. In this case the tubercle 
granulation is the exciting cause of the catarrhal pneumonia ; in the 
former the products of catarrhal pneumonia undergo the caseous change 
in consequence of a peculiar "invulnerability" of the constitution, 
without which the catarrhal products would pass through the ordinary 
changes. Dilatation of the bronchi, or bronchiectasis, plays an impor- 
tant part. In catarrhal pneumonia, the walls of the bronchi yield in 
consequence of an extension of the inflammatory process to them, and, 
as the existence of dyspnoea renders greater inspiratory efforts neces- 
sary, and as the area for the admission of air is much reduced, obvi- 
ously the interbronchial pressure is raised, so that greater force is ex- 
erted against the weakened tubes. According to Rindfleisch, the walls 
of some cavities are in part formed by dilated bronchi. Cavities, still 
extending, have no proper boundary, and are surrounded by tubercle 
and caseous masses undergoing softening, and by detritus of the lung- 
tissue. Others are lined by a connective-tissue membrane, which con- 
tinuously pours out a puriform matter of a greenish-yellow, often hav- 
ing a foul odor by reason of decomposition from the presence of air. 
When the cavity is recently formed, not only are its sides ragged and 
uneven, but large bands traverse it, remains of pulmonary tissue not 
destroyed. Other organs besides the lungs are affected. The ^:>Zewm 
is usually the seat of a chronic inflammation ; it may take the form of 
a dry pleurisy, and close adhesions form universally, so that the cavity 



PHTHISIS PULMONALIS. 



413 



is obliterated ; or the adhesions may be local and partial when they are 
chiefly at the apex ; or a neo-membrane is formed, and both the pleura 
and the new membrane may become tuberculous. Extensive effusion 
may be formed in consequence of the rupture of a cavity and the escape 
of its contents, when a pyopneumothorax results. A cavity perforated 
and firm adhesions having formed, the pleura may ulcerate and dis- 
charge take place through the thoracic parietes, a fistula remaining. The 
bronchial glands enlarge by hyperplasia of their contents, which un- 
dergo caseation. They may be dry and cheesy, or suppurate and dis- 
charge, the pus finding an exit by the trachea, or by a bronchus, or by 
the oesophagus. In infants and children, enlarged bronchial glands 
may compress the trachea or bronchi, or the pneumogastric, and thus 
give rise to suffocative attacks. It may be well to mention that the 
late Dr. Fuller, of London, had secondary pysemic abscesses of the 
brain, from suppurating bronchial glands. The larynx always suffers 
from some morbid change in pulmonary tuberculosis. From simple hy- 
perasmia up to extensive tubercular ulcerations, destroying the epiglottis, 
vocal cords, etc., there are numerous gradations in the severity of the 
lesions. Tubercular ulcerations also occur in the oesophagus, stomach, 
and intestines, but the point of greatest development of the ulceration 
is the lower part of the ilium and the large intestine. The tubercular 
troubles of the intestinal canal are found in two stages : the initial de- 
posit, and the softening and destruction of tissue or ulceration. The 
peritoneum is granulated, and chronic lesions of the peritoneum coin- 
cide with the formation of ulcers in the intestine. The liver is usually 
in an advanced stage of fatty degeneration, but in rare instances the 
change is that of amyloid disease. In the kidney, the amyloid degen- 
eration is more common than the fatty. Tubercular ulcerations are 
often found all along the urinary tract. 

Symptoms. — There is a peculiar type of constitution, as a rule, asso- 
ciated with tuberculous phthisis, which, being present, may serve to 
excite suspicions, at least, in obscure and doubtful cases. These pecu- 
liarities are observed in growing youths and young men, and may be 
described as follows : They are tall and rather thin ; the neck is long 
and small ; the thorax flat, narrow, and having but little expansile 
mobility ; the muscles, especially of the chest and neck, are thin and 
poorly developed ; the intercostal spaces are wide ; the hair is fine, the 
eyelashes long ; the eyes are large and bright, the sclerotic glistening ; 
the skin is transparent and thin, the color quickly changes, and the 
veins are blue and distinct ; the fingers are long and tapering, but their 
extremities are incurved or club-shaped. These subjects possess certain 
moral and mental characteristics also : they are impressionable, the dis- 
position is variable ; they are fond of activity, but fatigue easily ; oth- 
ers are more phlegmatic, speak slowly, and differ in complexion, being 
dark, with thick, muddy skins. When these peculiarities of constitu- 



414 



DISEASES OF THE KESPIRATORY ORGANS. 



tion coexist, with an hereditary tendency to phthisis, they possess a 
high degree of significance. In such subjects, cough, losing flesh and 
strength, with a red line along the margin of the gum, are strongly in- 
dicative of the onset of phthisis, even when the physical signs may not 
be positive. A large proportion of the cases begin by loss of appetite, 
indigestion, decline in weight, without cough or any symptom referable 
to the lung. In women these symptoms are accompanied by disorders 
of menstruation. Again, an attack of haemoptysis may be the first 
symptom. Most usually, the onset of the disease is characterized by a 
short, dry cough, which is rather more troublesome at night, preventing 
sleep, some shortness of breath, pains in the chest, either wandering or 
fixed in the position of an intercostal nerve, or a sharp stitch indica- 
tive of pleurisy, some nocturnal perspiration, confined at first to the neck 
and face, decline in flesh and strength, poor appetite, and often, more 
or less diarrhoea. At this period, too, some alteration of the voice is 
beginning to be perceptible and bronchial haemorrhage occurs. The 
progress of the case is more rapid if the fever now appears. This may 
be an early symptom ; it may be postponed until the period of soften- 
ing. The action of the heart is excitable and is accelerated by slight 
causes from the very beginning, and the pulse is soft and compressible, 
the tension of the vessels being low. The usual type of fever in the 
beginning is the quotidian. There is a daily morning remission, an 
evening exacerbation terminating in a sweat — the co-called hectic fever 
{septicmmiG fever). The type may be double quotidian — two paroxysms 
of fever each day— the first in the morning, the second at night. The 
range of temperature at this period is not great, the minima about 
98° Fahr., the maxima 102° Fahr. The range of fever-heat is an im- 
portant indication of the degree in which the morbid processes are 
proceeding, especially those involving the lungs. In illustration of 
this may be mentioned ijlithisis florida^ in which the highest tempera- 
ture of this disease is attained because of the immense extent of the 
caseous deposits undergoing softening and extrusion. As the case 
proceeds, all the rational signs become aggravated. The appetite is 
almost gone ; in severe paroxysms of coughing, in the last straining 
effort to dislodge the sputa, vomiting is excited, an accident very apt 
to occur after meals. The diarrhoea also increases, and becomes very 
difficult to restrain. The cough, also, grows more troublesome and 
painful, the expectoration more abundant, and the voice harsh and 
husky. Difficulty of swallowing comes on in consequence of ulceration 
of the epiglottis, and sometimes the attempts at swallowing are em- 
barrassed by the dropping of particles of food and drink into the glot- 
tis, exciting violent suffocative attacks. The expectoration assumes a 
different character at various periods. At first there is brought up, 
often with a great deal of effort, some frothy mucus ; after a time 
the sputa become purulent or muco-purulent, greenish or greenish- 



PHTHISIS PULMONALIS. 



415 



yellow in color, without air, and without viscidity, unless there is a 
complication of pneumonia, when the sputa will have a grayish, vitre- 
ous, adhesive character, and may also present a slightly rusty aspect 
from the admixture of blood, or may be simply streaked with blood. 
These adhesive sputa may be seen in large muco-pus expectorations, 
as isolated particles. The sputa often have a striated appearance, at 
one time supposed to have much significance, but now known to be 
produced by the diminution of the cellular elements and the presence 
of deformed and atrophied cells and of granules — changes of a degen- 
erative kind due simply to retention in the lung. A very significant 
element in the sputa is the presence of elastic fibers of the pulmonary 
tissue. These bodies are most easily detected by boiling the sputa in 
a solution of caustic soda in dis- 



tilled water (18—100) accord- 
ing to the method of Fenwick. 
The most distinctive element is 
the bacillus tuberculosis, which 
is necessary to constitute tu- 
bercle, according to the mod- 
ern conception. Well-developed 
specimens can usually be ob- 
tained from the expectorated 
matters, even in cases of the so- 




FiG. 35.— rragment of Limg-Tissue and Sputa. (Beale.) 



called " miner's li 



The next change in the sputa is the character- 



istic impressed on them by formation in small cavities. They then 
consist of two parts, a frothy muco-pus from the bronchi, and isolated, 
globular, compact masses without air, of a greenish or grayish color ; 
when allowed to stand, the former rises and the latter sinks to the bot- 
tom, and, if put in water, sinks quickly. The quantity of expectoration 
varies ; in the beginning, because then it is derived from a bronchial ca- 
tarrh ; afterward, according to the extent of the cheesy masses under- 
going softening, the size of the resulting cavities, and the degree in which 
bronchiectasis exists. When there is a large cavity, quantities of little 
more than pus are expectorated. When the patient lies in a position to 
permit accumulation to take place, the expectoration may be suspended, 
but, when the position is changed, the pus is discharged in a stream. 
Sputa streaked with blood and rusty sputa have already been alluded 
to ; but expectoration of blood, or haemoptysis, is a different affair. Ac- 
cording to some, phthisis may be due to pulmonary hsemorrhage. This 
notion arose from the clinical fact that haemoptysis is sometimes the 
first symptom of the disease, and after its occurrence there is an imme- 
diate development of the symptoms. The presence of blood-clot is 
supposed to excite an irritation which has for its ultimate effect the 
formation of tubercle. The most generally accepted view is, that hgem- 
orrhage is merely a symptom, and a symptom that may occur at any 



416 



DISEASES OF THE RESPIRATORY ORGANS. 



period. If we accept Rindfleisch's demonstration, that the formation 
of tubercle begins in the connective-tissue cells of the adventitia of the 
vessels, there can be no difficulty in comprehending the early appear- 
ance of haemorrhage in the course of phthisis. At any subsequent 
period, the extension of the area of tubercle formation may be ac- 
companied by haemorrhage. Again, haemorrhage, often considerable, 
may be due to the erosion of an unclosed vessel in the process of de- 
struction, ending in the formation of a cavity. The amount of blood 
lost varies from a drachm or two to several pounds. The blood is 
bright colored, more or less aerated, and comes up with coughing ; but 
a sudden large haemorrhage may pour up in a stream and be ejected 
by the nose as well as the mouth. A considerable part of the blood may 
be swallowed, and subsequently vomited, and, as it is then acted on by 
the gastric juice, presents the appearance of haematemesis ; but the 
history of the case, the rational and physical signs of pulmonary dis- 
ease and the absence of stomachal disease will afford the data for a 
correct diagnosis. After the haemorrhage has taken place, and the 
flow is arrested, for some days clots of small size and blackish in color 
are expectorated. Occasionally there are indications of the approach 
of a haemorrhage, the significance' of which the sufferers from them 
soon learn : these are a feeling of warmth in the chest, oppression 
of breathing, excited action of the heart, and a rather sw;eetish and 
saltish taste in the mouth. Usually, nothing in the nature of a warn- 
ing of the approaching haemorrhage is observed. When the blood- 
taste is experienced, the mouth should be examined, for the gums may 
be the source of the haemorrhage. Bleeding from the posterior nares 
may also be confusing, as there may be a coincident cough. A pul- 
monary haemorrhage may be vicarious of the menstrual flow, and it 
may be determined by the sudden arrest of haemorrhoidal bleeding. 



3. FIBROID PHTHISIS. 

Definition. — By this term is intended a form of consumption char- 
acterized by hyperplasia of the connective tissue of the lung and 
atrophy and degeneration of its proper structure. In this respect 
the disease corresponds to fibroid liver, fibroid kidney, etc., but the 
changes do not begin in and are not limited to the connective tissue. 
Bronchial inflammation, bronchiectasis, bronchorrhoea, and exudative 
pleuritis are among the initial changes, the pulmonary tissue being 
involved subsequently. Ultimately tubercular deposits occur, and the 
lesions produced by these are added to those already existing in the 
connective tissue and the bronchi. 

Etiology. — Heredity is concerned to the extent that the type of pul- 
monary tissue favorable to the development of this disease is trans- 
mitted. It is a disease of mature life, after the middle period, and is 
extremely rare before thirty. Next to heredity, chronic bronchitis and 



PHTHISIS PULMONALIS. 



417 



a form of pleuritis characterized "by extensive organized exudation are 
the most influential factors. The causes of chronic bronchitis are, 
therefore, indirectly the causes of fibroid phthisis. 

Pathological Anatomy. — The mucous membrane of the bronchi is 
of a dark red in the more recently inflamed parts, of a slate-color in 
the older, traversed by dilated vessels, its glands much thickened and 
elevated above the general surface. The sub-mucous connective tissue 
is thickened, the muscular layer hypertrophied at first, but in the fur- 
ther progress of the case the whole tube is softened and dilated. These 
dilatations may be fusiform or sacculated. The latter predominate, 
and are often mistaken for cavities, the resemblance being the more 
striking if the dilatation contains an accumulation of pus. The atro- 
phic changes in the walls of the bronchi are not the only factors con- 
cerned in producing dilatation. The force of the expiration in cough- 
ing, the contraction of the adjacent connective tissue, and of pleural 
adhesions, are also concerned. From the bronchi the inflammation 
slowly extends to the peribronchial, perivascular, and interlobular con- 
nective tissue. A hyperplasia of its constituent elements takes place, 
with the result to compress the vessels, the acini, and the bronchioles. 
The contraction of the newly formed connective tissue, by cutting off 
the blood-supply and encroaching on the neighboring parts of the pul- 
monary tissue, causes an atrophy. Some of the lobules collapse (ate- 
lectasis) ; all within the affected area contain less blood, and are nar- 
rowed by pressure. The collapsed lobules undergo the changes already 
described. In the progress of these cases catarrhal pneumonia ulti- 
mately plays a part ; the bacillus tuberculosis appears in the caseous 
masses, and these undergoing softening and extrusion, cavities are 
formed. So that the cases of fibroid phthisis, although differing in 
their rate of progress and in the greater importance of the sclerosis to 
the other morbid processes, nevertheless are brought into close relation 
to the other forms of phthisis. A considerable increase of the con- 
nective tissue of the lungs occurs in chronic tubercular phthisis ; the 
longer the duration of the disease, in fact, the greater is the develop- 
ment attained by it. The walls of the cavities are composed of a dense 
layer of connective tissue, closely united to the same tissue of the lung. 
In caseous pneumonia there is less production of connective tissue, be- 
cause of the rapid progress. In a fibroid lung the cavities do not attain 
to great dimensions ; they appear as interspaces in the dense trabe- 
culse. When these intervening portions of the condensed tissue are 
divided, they are ascertained to be exceedingly firm, of a grayish or 
slate color, containing here and there patches of brown pigment, and 
possess but little vascularity. The early compression and closure of 
the vessels is a source of mischief to the heart. The pulmonary circu- 
lation being obstructed over a considerable portion of the lung, the 
right cavities yield to the increasing pressure and dilate. There is, 
therefore, a stasis of the venous circulation ; the liver enlarges, and 



418 



DISEASES OF THE RESPIRATORY ORGANS. 



ascites is produced; the kidneys are congested, and albumen is present 
in the urine. These complications develop toward the close of the 
malady. 

A considerable proportion of the cases of fibroid phthisis originate 
in " dry pleurisy " — characterized by the formation of extensive solid 
exudation. Three varieties of this form of pleuritis are recognized : 
the fibrinous, the croupous, the proliferative ; * but it is probable the 
three processes are mixed in every case. An extension of the pleuritis 
takes place by contiguity of structure ; the connective tissue of the 
lung is entered by the interlobular fissures ; the peribronchial and 
perivascular connective tissue is invaded and undergoes proliferation, 
and then the alveoli become afPected. Thus the morbid process comes 
to involve all the pulmonary elements. At first a general conges- 
tion of the affected parts ensues ; then the exudative process occurs, 
and at length the deposit and puUulation of the bacillus are manifested 
by caseation, ulceration, and extrusion of the products of its develop- 
ment. The general course of the structural alterations of the pul- 
monary parenchyma is as already described. 

Symptoms. — Fibroid phthisis is the most chronic form of the dis- 
ease ; its early history is that of bronchial catarrh, or of dry pleurisy 
of the exudative form ; and it is not until after months, even years, 
that, extension taking place to the lungs, the progress becomes more 
rapid. For months there is merely a dry cough, not very troublesome, 
but persistent. The expectoration is slight, and is nothing but mucus. 
The appetite is but little impaired, and the weight and strength are 
not materially reduced. During the fall, winter, and spring months 
the symptoms increase in severity ; the cough becomes more trouble- 
some, and the expectoration more abundant and having the appearance 
of muco-pus. The symptoms ameliorate during the warm months, but 
to increase again with the changeable weather of winter. After two 
or three years of this alternation, there is less and less improvement 
in the warm months, but the symptoms of catarrh continue through- 
out the year. Fever comes on toward evening, the temperature at 
first rising to 100° Fahr. The appetite lessens, digestion becomes 
poor, and the body-weight progressively declines. The cough is har- 
assing and prevents sleep ; the expectoration becomes more profuse 
and entirely purulent ; and the food now and then comes up in the 
attempt to clear the larynx and fauces. Some diflSculty of breathing 
is experienced ; the pulse is small and weak ; the skin is warm toward 
evening, while slight chilliness is felt in the morning, and sweating 
occurs during the night. As the disease advances, the temperature 
reaches 101° and 102° in the evening, but it does not attain to the alti- 
tude reached in caseous or tubercular phthisis. When the bronchi 
dilate, the expectoration becomes profuse, especially in the morning — 



* Sir Andrew Clark's " Lumleian Lectures," "Lancet," vol. i, 1885. 



PHTHISIS PULMONALIS. 



419 



a cupful or more may be brought up in an hour or two. Fragments 
of fibrous tissue only appear in it when cavities are forming. At this 
period there may be one or more hsemorrhages. Detritus of caseous 
matter containing the bacillus, softening, is found in the sputa only at 
this later period. The onset of tuberculosis is announced by increase 
of dyspnoea, rise of the temperature, alterations in the voice, and diar- 
rhoea. The development of the connective tissue and the compression 
of the vessels lead to dilatation of the right cavities of the heart, stasis 
of the venous system, and congestion of the liver and kidneys. (Edema 
of the feet and ankles is first observed ; then swelling of the legs and 
scrotum, and ascites appear. 

Physical Signs of Phthisis. — There are no points of difference as 
respects the physical signs of phthisis ; hence the three forms may be 
considered together. 

The abnormality in the development of the chest, which is observed 
in phthisical subjects, has been already described. In the movements 




Fig. 36.— Cavities ; one partly filled, one empty. (Da Costa.) 



of the ribs during expansion in inspiration, deficiency may be observed 
to exist on the diseased side. On palpation, increase of the vocal fre- 
mitus exists over consolidated lung and over cavities, and is diminished 
or wanting over effusion in the pleural cavity. The percussion-note 
has great variety. All shades of dullness exist. If the consolidation 
is not complete and some air still enters the diseased area, the note is 
high-pitched, but with a somewhat tympanitic quality ; but if the tissue 
is entirely without air, then the note is high-pitched and hard in qual- 
ity. The change in sonority may be unilateral or double, but if double 



420 



DISEASES OF THE RESPIRATORY ORGANS. 



it is not necessarily symmetrical ; it may be infra-clavicular on one side, 
infra-spinous on the other. The dullness may be due to various causes 
— to a pleuritic effusion, to pneumonic consolidation, or to a tumor or 
cyst. The extension of the area of dullness and the increase in hard- 
ness or the disappearance of the tympanitic quality may indicate the 
increase of the tubercular or caseous deposition. The change in the 
sonority of the lung is most usually at the apex, but it may be in any 
situation. During the process of softening and extrusion there is no 
change in the character of the percussion-note until excavations have 
formed ; even then there will be no change, unless the cavity be large 
and near the surface. The percussion-note may present a nearly nor- 
mal sonority or it may be exaggerated over a cavity ; it may have a 
metallic clang, or amphoric quality ; it may, if the cavity communi- 
cate with a bronchus, have the cracked-pot sound {bruit de pot fele). 
The last is produced by strong percussion, the vibrations occurring 
in the walls of the cavity and in the column of air in the bronchus, 
A cavity in which pus has accumulated may furnish a dull sound ; 
when emptied, the amphoric sound w^ll return. On auscultation the 
sounds audible will present great variety. The vesicular murmur will 
be unimpaired in those parts free from disease ; it will be feeble or in- 
distinct if many bronchioles are obstructed ; it will be rude or blow- 
ing if the bronchioles are narrowed ; inspiration will be jerking and 
expiration prolonged and blowing if the lung has lost its elasticity 
from any cause. These signs are much less significant when they 
occur on the right than when they occur on the left side (infra-clavicu- 
lar regions) ; in the former situation, they are, so to speak, normal. 
Next to these modifications in the respiratory murmurs are certain 
adventitious sounds, or rales. The earliest of these audible in the in- 
fra-clavicular region usually is a fine, dry, crackling sound (sub-crepi- 
tant) appearing at the end of inspiration, and sometimes requiring a 
deep and full inspiration to develop it. This rale may be temporary, 
when it has but little significance. The extension of the inflammation 
to the larger bronchi induces more abundant secretions, and the 
sub-crepitant rale becomes a distinctly moist sound, and audible over 
a larger area, and coarser sounds also moist — mucous rales — are 
mixed with them. With these rales changes in the respiratory sounds 
take place : inspiration has a distinct blowing character which approxi- 
mates to and ultimately does become bronchophonic — i. e., the sound 
of the movement of the air in the bronchial tubes and of the voice are 
communicated to the ear directly, the solidified lung acting as a good 
conductor, the respiratory or vesicular murmur having disappeared. 
These are the sounds of consolidation, and of softening up to extru- 
sion. When cavities form, new sounds become audible, but it is not 
always easy to differentiate between bronchophony and amphoric and 
cavernous blowing, the signs of a cavity. Amphoric blowing and 



PHTHISIS PULMONALIS. 



421 



amphoric voice are signs of a cavity, if correctly interpreted ; the cav- 
ernous sounds produced in a large cavity with thin walls are more sig- 
nificant. To these must be added metallic tinkling, which is heard in 
perfection in hydropneumothorax and under similar conditions when 
the cavity is large. 

Course, Duration, and Termination. — The course of phthisis is 
much influenced by its form. Phthisis florida, or acute caseous 
phthisis, runs its course in a few months, and not often with intermis- 
sions, although it does sometimes intermit, and then pursue a more 
chronic course. Its usual course is continuous — a large part of one or 
of both lungs may be occluded, softening occurs, and high fever with 
rapid emaciation soon exhausts the powers of life. The usual type of 
caseous phthisis is chronic ; there are repeated bronchial attacks and 
gradually increasing consolidation, the interval between the attacks 
being characterized by varying degrees of improvement, but with a 
general tendency toward decline. In many, it is true, under judicious 
management, the catarrhal process is arrested, absorption of the case- 
ous matter takes place in part, the rest is extruded, with more or less 
destruction of tissue ; cicatricial tissue supplies the place, contraction 
ensues, with subsequent retraction of the chest-wall, and thus, in a 
limited sense, a cure is effected. In other cases the course is less 
marked by intermissions, the caseous deposits are extensive, and there 
are haemorrhages, fever, emaciation — the symptoms continuing until 
death. While the duration of the former type may be two, three, and 
as much as five years, or during the ordinary duration of life, the latter 
do not often extend two years. The tuberculous form also pursues 
two different courses : one chronic, developing slowly, lasting two 
years or more ; the other more rapid, the whole course being termi- 
nated within a year. The degree in which broncho-pneumonia, atelec- 
tasis, and dilatation of the bronchioles occur, the extension of the tuber- 
culosis to the larnyx and intestinal canal, and the number and severity 
of the haemorrhages, are important factors in bringing about a fatal re- 
sult. So long as the tubercular deposit is limited to the lung, is slight 
in extent, there is a possibility of recovery by extrusion, shrinking of 
the lung, and retraction of the ribs. The most chronic of all the 
forms of phthisis is the fibroid. The course of this may occupy sev- 
eral years, indeed an ordinary lifetime, and prove fatal at last. Of all 
the forms, it offers the best prospect of a cure, if the changes are not 
too extensive. The initial period, terminating in a bronchiectasis, may 
occupy a number of years ; at first, for several years, there is winter 
cough only, the warm season being free, or nearly so ; when the con- 
nective tissue of the lung is invaded the progress is more rapid, for 
then atelectasis and caseation enter as elements into the destructive 
changes. Finally, tuberculosis is ingrafted into the morbid process, 
which then advances more rapidly, because not only the lungs, but the 



422 



DISEASES OF THE RESPIRATORY ORGANS. 



larynx and intestinal canal, become diseased ; the range of temperature 
rises higher, and emaciation proceeds at an accelerated pace. Phthisis 
is the great enemy of the human race, since nearly two sevenths of 
the deaths from all causes are due to this disease. But a few years 
ago, a cure of any case was regarded as hopeless ; but within recent 
times the improvements in our knowledge of the local conditions and 
in the means of treatment have led to better results, and cures are 
now nob uncommon. 

Diagnosis. — The diagnosis of phthisis can not be doubtful after 
the initial period. Incipient phthisis may be confounded with atonic 
dyspepsia. A cough may be present in atonic dyspepsia — the so-called 
stomach-cough. The natural differences in the sonority and the res- 
piration of the right and left infra-clavicular regions may materially 
contribute to the error. Attention to this, and to the fact that there 
is no point of irritation about the air-passages to account for the exist- 
ence of a cough, will settle the doubts. More frequently, in malarious 
regions, is hectic fever confounded with intermittent, since in the lat- 
ter there is usually some cough. This mistake is made when the pul- 
monary disease is quite advanced, so that the error is either from 
ignorance or carelessness. In phthisis, independently of the physical 
signs, the fever has been preceded by a period of cough, and loss of 
flesh and strength, whereas in intermittent these symptoms have fol- 
lowed the access of fever ; in phthisis there is not, in intermittent 
there is, an enlarged spleen ; in phthisis the hectic is not arrested by 
large doses of quinine ; in intermittent the fever is arrested and con- 
valescence is at once established. A careful study of the physical 
signs ought at once decide the question. Laryngeal symptoms are 
often so pronounced in the beginning as to obscure the pulmonary 
affection. Indeed, the disease in the lungs is referred by some to the 
larynx, to which it is regarded as strictly secondary. This error has 
arisen from the fact that considerable infiltration of the lung may exist 
without seriously impairing its sonority, or changing or modifying 
the vesicular murmur. When tubercular deposits occur in the larynx, 
the tone and quality of the voice are quickly affected, so that the lat- 
ter may seem to be the only seat of tubercular deposit. Although, to 
determine this question, time may be necessary, the coexistence of 
pulmonary disease ought to be suspected, because of the relation 
known to obtain between them. The most important diagnostic ques- 
tion relates to the difference between caseous and tuberculous phthisis. 
The sections devoted to these two forms have indicated the clinical 
and pathological differences ; nevertheless, it will be useful to state 
briefly the points which serve to distinguish them. Tubercular phthisis 
is distinctly hereditary ; caseous phthisis is not hereditary, but occurs 
in the scrofulous. Tubercular phthisis occurs at all ages ; caseous, 
from youth to middle age. Tubercular phthisis occurs insidiously 



PHTHISIS PULMONALIS. 



423 



with catarrh of the bronchi and larynx ; caseous results from acute 
inflammations of the bronchi and lungs. Tubercular phthisis is more 
often than the caseous a cause of pulmonary haemorrhage. In tuber- 
cular phthisis the lesions are apt to be on both sides ; in caseous, on 
one side. In tuberculosis of the lung, tubercle may be widely dissem- 
inated without any striking physical signs ; in caseous phthisis the 
caseous deposits produce very pronounced physical symptoms. The 
laryngeal symptoms are much more common in tubercular than in 
caseous phthisis. The progress in tuberculous phthisis is more rapid 
and the mortality greater than in caseous. Fibroid phthisis is distin- 
guished from the other forms by its slow progress, by the long period 
of bronchial troubles before the pulmonary lesions begin, by the merely 
purulent expectoration, without fibrous tissue, until late in the prog- 
ress of the case, and by bronchial dilatation long before the cavities 
by excavation form. 

Treatment. — When a phthisical tendency exists, prophylaxis be- 
comes highly important. Although not often consulted, physicians 
should discourage, directly and indirectly, the marriage of the phthisi- 
cal. Children inheriting the dyscrasia should have a careful physical 
training, substantial food, warm clothing, and exercise in the open air 
without exposure. They should be guarded against attacks of bron- 
chial catarrh, of measles, and whooping-cough, for in these diseases 
the seeds are sown of future mischief. As humidity is such an im- 
portant factor in the etiology of phthisis, and as dryness and elevation 
are climatic conditions of the greatest utility, if possible, the growing 
child should be separated from the one and placed in the other. Sing- 
ing should be encouraged, since that tends directly to improve the nu- 
trition of the lung, especially of the apex. Cold bathing should be 
practiced every morning to diminish the susceptibility to cold. Ca- 
tarrhal attacks occurring should receive prompt attention, and any 
lingering remnant of local morbid action should be carefully removed. 
The tendency to such attacks and the removal of the effects produced 
by them are equally controlled by the iodides (iodide of iron) and cod- 
liver oil. As phthisis is preeminently a wasting disease, it is highly 
important to put the organs concerned in nutrition into the highest 
state of efficiency. In tubercular and fibroid phthisis, among the ear- 
liest symptoms are stomach disorders, poor appetite, atonic or acid 
indigestion, and especially repugnance to the fatty elements of food. 
The mineral acids, with a bitter, such as tincture of nux vomica, are 
especially serviceable. If there be acid eructations, pyrosis, and heart- 
burn, the mineral acids, especially nitric (ten to fifteen drops, well 
diluted, Ur in die), should be administered before meals ; but, if the 
condition be atonic indigestion, the acid should be given after meals. 
The nuX'Vomica tincture should be given before meals — fifteen drops 
in water. The aliment should consist of easily digested articles of diet, 



424 



DISEASES OF THE RESPIRATORY ORGANS. 



and the stomach should not be overloaded under any circumstances. 
It should never be forgotten that it is not the quantity swallowed, but 
digested and assimilated, which contributes to the nourishment of the 
bodyo There are certain tonics to the stomach which stimulate the 
organ to more efficient work, that are very beneficial in promoting the 
nutrition of the body. These are, besides the bitters and mineral acids 
mentioned above, small doses of arsenic and silver, and alcohol. Arsenic 
is deserving of special commendation — in incipient phthisis, to promote 
the appetite and favor tissue-forming, while it corrects the disordered 
state of the stomach mucous membrane, and as a remedy for chronic 
tuberculosis and fibroid lung. The author must impress on his read- 
ers that arsenic must be given in small doses, as it is to be continued 
for a long period (two drops three times a day). The oxide of silver 
performs much the same office, but its administration must be brief, 
because of the danger of coloring the skin (Argyria). Small doses of 
alcohol after meals (half an ounce for adults) are highly useful to pro- 
mote appetite and tissue-formation. Physicians should not encour- 
age the dangerous notion that whisky is antidotal to phthisis. Fibroid 
phthisis appears to be produced by chronic alcoholism. Large quan- 
tities of alcoholic fluids impair the function of digestion, and lessen 
tissue-forming ; hence the amount named — certainly not more than 
twice as much — should not be exceeded. The utility of cod-liver oil 
in incipient phthisis is very great. As the power to digest fats is con- 
fined within narrow limits, and as the ability to dispose of them is 
relatively less in consumption, the dose of cod-liver oil should be pre- 
scribed accordingly, from a tea- to a tablespoonful — a teaspoonful the 
usual dose. All in excess of the capacity to digest passes unchanged, 
and may be seen floating on the evacuations. The utility of cod-liver 
oil consists in the fact that it is a fat, having a special digestibility, 
owing to its containing bile elements, and is therefore peculiarly fitted 
to form the " molecular basis of the chyle." It is not useful in cases 
of phthisis florida, or in caseous phthisis characterized by large de- 
posits, high fever, and diarrhoea. In incipient phthisis its utility is 
very great, and only less so in chronic tuberculosis and fibroid phthisis. 
In what form soever it may be given, it is better to prescribe it with 
a little ether {y\, xx — 3 j), because of the action of the ether in pro- 
moting the flow of pancreatic fluid — a fact demonstrated by Bernard, 
and confirmed by clinical observation. Cod-liver oil may be given in 
the form of emulsion with the lactophosphate of lime, the compound 
hypophosphites, and the compound phosphates. The simultaneous 
administration of these remedies is good practice, and the emulsion 
may be allowed, if the quality of the cod-liver oil is good, but it should 
not be overlooked that an inferior oil may be disguised in an emulsion 
of this kind. The lactophosphate of lime, if well prepared, is a most 
valuable agent in the treatment of incipient and the more chronic 



rUTHISIS rULMONALlS. 



425 



cases of phthisis. The hypophosphites, although not deserving the 
encomiums first pronounced on them as remedies for consumption, are 
valuable agents to promote the constructive metamorphosis. It is 
doubtful whether the hypophosphites present any advantages over 
the phosphates, because of their chemical instability and rapid conver- 
sion into the phosphates. The lactophosphate of lime has the special 
advantage that it is a soluble combination of an agent very important 
to the construction of tissue. The last-named remedy may be given 
in a dose of a tea- to a dessertspoonful of the sirup three times a day, 
after meals. It is good practice to give it with cod-liver oil, but not 
in an emulsion, for reasons already stated, unless the emulsion is pre- 
pared extemporaneously from unquestionable materials. If caseous or 
tubercular deposits have formed, we have a new problem for solu- 
tion. Do we possess means to procure softening, absorption, and 
extrusion ? The author has seen such good results from the salts 
of ammonia that he believes this question may, with some important 
limitations, be answered in the aflirmative. A combination of the 
carbonate and iodide of ammonium seems to procure the best results 
— five to ten grains of the carbonate and the same quantity of the 
iodide in solution in water. If the stomach is irritable, the dose 
must be small. As a rule, five grains of each remedy four times a 
day is better than a larger dose less often. Minute doses of cor- 
rosive chloride of mercury, the most efiicient parasiticide, should 
be given from the outset of the local symptoms, and continued per- 
sistently. 

Some of the chief symptoms require remedies to restrain them 
within proper limits, as cough, fever, sweats, haemorrhage, laryngeal 
symptoms, and diarrhoea. These we consider in turn. If cough is 
very distressing, some relief becomes necessary, and the constant temp- 
tation is to resort to anodynes. Gargling the throat with a solution 
of bromide of potassium, applying a mixture of chloral and camphor 
by means of a camel's-hair brush to the fauces, the atomization of a 
solution of cocaine, or of morphine, are expedients temporarily bene- 
ficial. Fothergill's prescription of hydrobromic acid (diluted) and 
spirit of chloroform sometimes acts well, but is often inefiieient. Of 
the principles contained in opium, codeine is the least objectionable ; 
it causes less disturbance of the digestive organs, and has more effect 
on cough. A combination of codeine, atropine, and strychnine is 
highly efficient as a remedy for cough, for night-sweats, and reflex 
vomiting. Picrotoxin allays the vomiting w^hich accompanies the 
cough almost as efficiently as strychnine, and has at the same time de- 
cided anhydrotio effect. A resolute patient may suppress cough to a 
very great extent by an effort of the will. The irritable feeling in the 
fauces may be allayed by a bit of gum-arabic or candy, or a troche. 
The officinal troche of licorice and opium, or of morphine and ipe- 



426 



DISEASES OF THE RESPIRATORY ORGANS. 



cac,* or a troche containing a small quantity of cocaine (|- to ^ gr.) may 
be employed in this way advantageously. In the treatment of the 
fever of phthisis, the first and most important remedy is rest. Under 
a mistaken notion of the value of exercise, phthisical subjects, having a 
high fever, attempt an active out-door life. A very considerable in- 
crease of the normal increment of fever takes place when exercise is 
attempted, and a corresponding diminution when repose is enforced. 
As a high range of temperature is most injurious, it is necessary to 
reduce it as much as possible. The most effective antipyretics are an- 
tipyrin and quinine, administered in anticipation of the period of 
pyrexia. Digitalis is too nauseating to be used with advantage, and 
salicylic acid is more unpleasant in all respects and less efficient than 
quinine. The most powerful anhydrotic which we possess is atropine. 
For an adult about -^q of a grain at bed-hour usually suffices ; but, as 
atropine seems to have a special action on the lungs in caseous pneu- 
monia, it is better to give it in smaller doses {^^-q to ^j- grain) twice 
a day. Under its use there is often a remarkable improvement in the 
condition of the patient, not dae solely to the arrest of night-sweats, 
but to some special property. The combination before referred to is 
a suitable form for the administration of atropine — with codeine and 
picrotoxin. Sometimes remarkably good results follow the use of pi- 
crotoxin, but it is far from being uniformly successful. If atropine 
fails, picrotoxin should be tried. Oxide of zinc, with belladonna ex- 
tract, sometimes does well. Sponging the body with hot water, or 
vinegar and water, is a domestic remedy, which is refreshing. Reme- 
dies for the laryngeal symptoms can be applied directly, the hand 
being guided by the mirror. Nitrate of silver, carbolic acid, and iodo- 
form are the medicaments most frequently thus used. Atomization 
and inhalation of vapors are, however, more useful and generally em- 
ployed. Common salt, potassic chloride, ammonium chloride, corrosive 
chloride, tannic acid, carbolic acid alone or with tincture of iodine, 
creosote, ethyl iodide, are the remedies most frequently used in this 
way. Those used by atomization are dissolved in water, or in glycer- 
in and water, for example, gr. ij of tannin to the ounce of water, the 
patient receiving the spray in the fauces. Inhalation of vapors, such 
as ethyl iodide, creosote, tincture of iodine, carbolic acid and tincture 
of iodine, is of unquestionable utility, and should constitute a part of 
the treatment in every case. The simplest means suffice to vaporize 
these agents, and the vapor can be drawn into the lungs by deep, slow 
inhalations. 

The diarrhoea of phthisis is most difficult of control, and for ob- 
vious reasons — the tubercular deposit and the subsequent ulcerations. 

* Trochisci glycyrrhizae et opii, eacli troche coBtaius ^ grain of opium ; trochisci 
morphinae et ipecacuanhse, each troche contains 4*0 grain of morphine and ^-^ ipecac. 



HEMOPTYSIS. 



427 



Opium and acetate of lead, opium and tannin, opium and sulphuric 
acid, opium and arsenite of potassa, are among the principal remedies. 
Extract of logwood is highly esteemed by many English practitioners. 
The author has had better results from Fowler's solution and the 
tincture of opium than any other remedies (2 gtt. to 10 gtt.) except 
aromatic sulphuric acid and laudanum (15 gtt. to 10 gtt.). In the 
treatment of the diarrhoea frequent changes are necessary. A remedy 
that succeeds for a time will not continue to do so, and hence the re- 
sources of the physician are often severely tried. 

The requisites of a climate for pulmonary invalids have been briefly 
stated ; they are dryness and elevation. The health-resorts which 
offer these requisites in the highest perfection are the best. Those of 
^^'orth Carolina, South Carolina, Georgia, the Rocky Mountain regions, 
California, New Mexico, offer every variety. No change of climate, 
however, can be beneficial as a rule, after cavities have been formed, 
unless of slight extent. It is in incipient phthisis that a change to a 
climate dry, bracing, and elevated, really exerts a curative influence. 

HEMOPTYSIS— BRONCHO-PULMONARY HEMORRHAGE. 

Definition. — The word hceinoptysis, which means "spitting of 
blood," does not indicate the source of the haemorrhage. JBroncho- 
pulmonary JimmorrJiage is a correct designation, for this expresses 
both the nature of the accident and the position of the disease. Bron- 
chial haemorrhage occurs from some part of the bronchi ; pulmonary 
haemorrhage consists of two forms — pulmonary infarction / pulmo- 
nary apoplexy — a h^emorrliage arising from embolic blocking of a 
branch of the pulmonary artery, the tissues of the lung being dis- 
placed merely in the former, but broken up in the latter. 

Causes. — Pulmonary haemorrhage is infrequent at the extremes of 
life, and is most common from youth up to middle life. It occurs in 
either sex in about the same ratio. An infarction presents a character- 
istic appearance of a wedge-shaped portion of the lung infiltrated with 
blood, and situated at the periphery of the lung, with the base of 
the wedge outwardly. Infarction is almost always associated with 
heart disease, in which heart-clots are formed on the right side, and 
emboli being detached pass into and obstruct a branch of the pul- 
monary artery. To cause an infarction, the artery obstructed must 
be a "terminal artery" in the sense intended by Cohnheim* — that is, 
an artery without anastomoses, and dividing only into the final capil- 
laries. When such a vessel is obstructed, the blood-current is arrested 
both in front and behind the point of obstruction, in the capillaries 
and veins, until they are joined by others. Then commences a back- 
ward current into the capillaries of the occluded vessel, and into the 
* " Untersuchungen ueber die embolischen Processe," Berlin, 1872, p. 74. 



428 * DISEASES OF THE RESPIRATORY ORGANS. 



vessel itself, until they are thoroughly distended with red blood-cor- 
puscles, and hence appear to the eye as a red spot having a wedge 
shape. In another form of infarction, a diseased vessel giving way, 
the blood enters a bronchus, and is drawn up into the lobules, distend- 
ing them. This differs from the other form in appearance ; it is less 
dark in color, is irregular in outline, and is shaded off into the sur- 
rounding normal tint. 

Pulmonary apoplexy is a hfcmorrhage which breaks up and infil- 
trates the lung, and is usually due to traumatism, to gunshot injuries 
and contusion, to the rupture of aneurisms, to gangrene, etc. Bron- 
chial haemorrhage arises from primary and secondary causes. The 
primary causes are of an irritative kind, and induce congestion : pro- 
longed exertion of the voice, mechanical straining, inhalation of irri- 
tating gases and fumes, etc. An abnormal weakness of the vessel-wall 
inherited ; that state of the circulation which exists in the subjects of 
haemophilia, the so-called " bleeders " ; the condition of the vessels in 
young subjects of the strumous type, are factors in the production of 
bronchial haemorrhage. The most important of the causes is tubercu- 
losis. As has been stated elsewhere, the initial change in the develop- 
ment of pulmonary tubercle is a proliferation of the connective-tissue 
corpuscles of the adventitia ; and, although the multiplication is chiefly 
outwardly, the media and intima are weakened. Haemorrhage may 
therefore be an early symptom of tubercular deposit. In the extension 
of the tubercular deposit a vessel may be invaded at any time. A large 
haemorrhage may result from the opening of a vessel by erosion in the 
process of softening and formation of cavities, or by the development 
of an aneurism on a vessel in the wall of a cavity. The vessels still per- 
vious are subjected to a much greater pressure by reason of the closure 
of so many, and hence this increase in the vascular pressure enters into 
the question of haemorrhage. The suppression of an habitual discharge 
has long been supposed to cause pulmonary haemorrhage, but this is no 
longer admitted. The menstrual flow may take place vicariously by 
the bronchial mucous membrane, as it does by various channels. A 
substitution is very different from a vicarious haemorrhage. 

Pathological Anatomy, — Haemorrhage may be caused by a diape- 
desis of red-blood globules, and hence no solution of continuity can be 
detected under such circumstances. Even when there has been a con- 
siderable haemorrhage, the source of it may elude the most painstaking 
investigations. If the examination is made immediately after a haem- 
orrhage, there will be found both fluid and coagulated blood, drawn 
up into the bronchioles and alveoli, and through the larger tubes. In 
consequence of violent struggles for breath, in the case of large haem- 
orrhage, the inspiratory efforts draw up a good deal of blood into the 
lungs, distending them, so that they overlap the heart and do not col- 
lapse. They present a mottled appearance, because of the filling of 



HEMOPTYSIS. 



429 



matny alveoli with blood. The mucous membrane of the bronchi may 
be congested or reddened by patches of extravasation, or of a dull-red 
by imbibition of blood, or uniformly pale from ansemia, according to 
the causes producing it and the source of the haemorrhage. The in- 
farction presents a most characteristic appearance : it is wedge-shaped, 
with the base outward, and is, when small, just under the pleura ; when 
large, nearer the root of the lung. Infarctions vary in size, from a 
pigeon's to a hen's egg, or may even occupy a half or nearly the whole 
of a lobe. They are found more frequently in the inferior part of the 
lower lobe. If under and next the pleura, they appear as dark-blue 
masses, projecting somewhat above the general surface of the lung, 
which just about the infarction is pale and exsanguine, while the 
pleura is roughened by exudation, confined to the infarction. Some- 
times effusion occurs in the pleural cavity, which contains flocculi of 
membranous exudation, and is red by admixture with blood. When a 
section is made through an infarction, it appears as a dark, reddish- 
blue, well-defined mass, from which some dark, reddish-brown liquid 
a^nd granular matter may be pressed. Fibrinous exudation, distending 
some of the alveoli, gives to the otherwise smooth surface a granular 
aspect. At first firm and elastic, the infarction soon becomes friable. 
The surrounding pulmonary tissue is more or less hypersemic and 
oedematous. An infarction may undergo several kinds of change : the 
blood may disintegrate, the fibrin become granular and fatty, and the 
corpuscles break up into fat-granules ; absorption may take place in 
part, extrusion in part, and recovery ensue, the elasticity of the lung 
remaining impaired to some extent. Recovery may ensue in part 
only : the lobules collapsing and inflammation occurring in the con- 
nective tissue, a brownish-red indurated mass remains ; or, after an 
imperfect absorption of the blood and inflammatory exudation, the 
remaining reddish, pulpy mass solidifies by infiltration with calcareous 
salts, or, merely inclosed by a limiting membrane, a cyst remains — a 
process only resembling haimatoma of the dura mater. Or, again, 
inflammation may result in suppuration, an abscess forming ; or, finally, 
the whole may become gangrenous. Pulmonary apoplexy not unfre- 
quently forms a blood-mass of considerable size, the blood breaking 
up the pulmonary elements and diffusing into the surrounding parts, 
in part coagulating. If next the pleura, this membrane may be per- 
forated, and the blood, entering the cavity, produce a hsemothorax. 

Symptoms. — It is but rarely that a hemorrhage occurs in full health 
without the least intimation of its approach. In this way may the 
onset of pulmonary disease be announced. Usually there is a sense of 
heat and oi^pression of the chest, which those recognize who have 
experienced former attacks, or there may be general vascular full- 
ness, headache, vertigo, palpitation of the heart, a quick, strong pulse, 
etc. The signs of pulmonary disease precede the haemorrhage, in 



430 



DISEASES OF THE RESPIRATORY ORGANS. 



a majority of cases, rather than succeed to it. At the moment the 
attack is experienced, there are a sudden cough, a warm feeling under 
the sternum, and a mouthful of fluid, tasting both saltish and sweet- 
ish, comes up. Cough now succeeds cough, and with each effort a 
teaspoonful or more of blood, somewhat frothy, or, if in large quan- 
tity, bright — red blood and somewhat darker clots, are discharged. 
Even with a small amount of blood, the moral effect of the blood-spit- 
ting is so great that much depression, paleness of the face, and a weak 
pulse result. If the loss be great, there will come on the subjective 
sensations of fainting, and actual syncope will happen. If the hsemor- 
rhage is great, the blood will come up with a sudden gush, spurting 
from the nose as well as the mouth. If a fatal haemorrhage, the blood 
will pour out of the mouth and nose, there will be gurgling in the 
fauces, frantic efforts at respiration, a deadly pallor will overspread the 
face, and, with a general convulsion in which the breathing ceases, all 
is over, but the heart will beat for a minute longer. The expectora- 
tion of blood does not cease with the arrest of the haemorrhage ; for 
some days subsequently dark-brownish coagula will be brought up, with 
some rather viscid mucus. The source of the haemorrhage may not 
unfrequently be determined by the moist rales heard in the bronchi. 
The signs and symptoms of infarction have already been mentioned 
under the head of embolic pneumonia, so that it is necessary only to 
mention that, when an infarction of sufficient size is formed, the symp- 
toms are sudden dyspnoea and the physical signs of consolidation. 

Course, Duration, and Termination. — There are great variations in 
the amount and duration of pulmonary haemorrhage. The whole 
course may be concluded in a few hours. The expectoration may go 
on during several days, from a tea- to a tablespoonful being spat up 
each time, and the haemorrhage in the aggregate amounting to several 
pounds, causing great depression and a tedious convalescence. In 
other cases, there may be a number of large haemorrhages, occurring 
after an interval of several days, the arrest being due to syncope, and 
the hiemorrhage recurring when sufficient blood has been made to pro- 
duce it. Such cases may continue for several weeks, the system being 
much reduced and the convalescence very protracted. In cases of 
haemorrhage with infarction there will follow a period of inflammatory 
reaction, the expectoration will continue bloody for a week or ten 
days, and, if the area of tissue involved is small, recovery will ensue, 
and convalescence will be established in about ten days. The reader 
is referred to embolic pneumonia for further details in respect to this 
group of cases. An ordinary croupous pneumonia may be accom- 
panied by considerable haemorrhage, which occurs with the initial 
hyperaemia, when the pneumonic process may be confounded with 
the results of haemorrhage. The debility caused by pulmonary 
haemorrhage is quite disproportioned to the actual loss. A few tea- 



HEMOPTYSIS. 



431 



spoonfuls may induce fainting and an unexpected degree of anaemia. 
Any considerable loss will be followed by pallor, weakness, breathless- 
ness on slight exertion, palpitation, etc., and the restoration of the 
blood will require several weeks or months. The moral effect of the 
haemorrhage and the association of ideas connected with the bleeding 
are in part responsible for the depression, but more is due to the fact 
that, in most cases, the system is already enfeebled by a dyscrasia. 
To this important element is also due the prolonged condition of 
anaemia — the slow reproduction of the red blood-corpuscles. 

Diagnosis. — In every case of doubt, the mouth, fauces, and nares 
should be carefully examined. Is it vicarious haemorrhage? The 
patient is a female, the haemorrhage occurs at the menstrual epoch, 
and takes the place of the menses, or nearly so, and no untoward re- 
sults are experienced, nor does any evidence of pulmonary disease 
exist. In many of these supposed vicarious haemorrhages it will be 
found that the subjects are of the phthisical type, and that, if the 
physical signs are wanting, there are suspicious rational symptoms. 
In these cases, it usually happens that the menstrual flow does not 
return, and that phthisis rapidly develops. Haemopt3^sis is to be dif- 
ferentiated from hasmatemesis. In the latter, the blood is black, con- 
tains no air, has an acid reaction, is mixed with articles of food, and 
is vomited ; in the former, the blood is bright red, contains air, has 
an alkaline reaction, and is coughed up, while there is no nausea. If 
the blood of pulmonary haemorrhage is swallowed, it will present the 
characteristics of blood derived directly from the stomach, but the 
distinction is then made by observing that some of the blood is 
coughed up, and has the ordinary character of blood derived from the 
lungs. It should be noted that blood swallowed may pass away with 
the stools. Haemoptysis is accompanied by rales in the chest, and 
preceded in the largest number of cases by symptoms referable to the 
chest ; haematemesis by symptoms referable to the stomach. 

Prognosis.^ — It is very rare indeed for the life to be put in jeop- 
ardy by a pulmonary haemorrhage. If the patient is much reduced, a 
severe haemorrhage may materially hasten a fatal result. Haemor- 
rhage proceeding from a cavity is more unfavorable than a bronchial 
haemorrhage, for the vessel may bleed again and again, since any co- 
agulum, which in other situations might close it, will here be readily 
detached. The prognosis must be guarded when the subject of the 
haemorrhage is much reduced and the quantity lost is considerable. 
In a case of supposed vicarious hremorrhage, the probability of a 
rapid development of the pulmonary lesion should not be forgotten. 

Treatment. — The management of cases of hemoptysis includes the 
treatment of the haemorrhage and of the conditions on which the 
haemorrhage depends. If the subject be a plethoric one, and there is 
much oppression from fullness of the vascular system, bloodletting 



432 



DISEASES OF THE RESPIRATORY ORGANS, 



may be practiced, either by venesection or by application of a dozen 
leeches. These are, it must be admitted, rare cases. The most effective 
remedy is the hypodermatic injection of ergot. Often, the most severe 
bleeding will be at once arrested, when other means of treatment had 
been employed in vain. Fluid extract of ergot may be given inter- 
nally, combined, if desirable, with digitalis and opium — with digitalis 
if the action of the heart is rapid and excited, and with opium if there 
is a troublesome cough. Ipecac is, next to ergot, one of the most effi- 
cient haemostatics. Its utility has been disputed on theoretical grounds, 
but not by those who are practically acquainted with its real advan- 
tages. Ipecac produces an exsanguine condition of the lung, and ar- 
rests haemorrhage also, by the enfeebling effect of nausea on the heart. 
It is even successful in stoY>^ing post-partum haemorrhage. Besides its 
haemostatic effect, one advantage of its use consists in mechanically 
clearing the alveoli of retained clots. Ipecac should not be prescribed 
in those cases of haemorrhage from a cavity, the difficulty of keeping 
a clot in the position necessary to close the vessel being already great. 
The most suitable form for the use of ipecac is the fluid extract, which 
may be combined with ergot, digitalis, and opium if desirable. Tinc- 
ture of veratrum viride may be used with great advantage to keep down 
the action of the heart. Ice has a similar effect to these dynamical 
haemostatics ; it slows the heart and contracts the arterioles. It should 
be applied to the chest, especially to the nape of the neck. The alter- 
nate application of heat and cold is usually more effective than the 
continuous cold. A sponge dipped in hot water can be applied first, 
then an ice-bag, and so on alternating — the heat reraaiping in contact 
but a few minutes, while the cold is kept applied the rest of the time. 
Absolute rest is an agent of the same kind. The patient should main- 
tain a recumbent posture, and not exert a muscle if he can exercise 
such restraint. All emotional disturbances should be avoided as well. 
There are remedies called astringents which are supposed to possess 
haemostatic powers, such as tannic and gallic acids, acetate of lead, 
alum, and the mineral acids, especially sulphuric. These are decidedly 
inferior to the remedies above named, yet they are freely used, espe- 
cially the acetate of lead in combination w^ith opium. That they are 
serviceable, an immense experience confirms, but they do not deserve 
the very great confidence reposed in them by many practitioners. In 
cases of debility, characterized by relaxation of tissue, or in examples 
of the haemorrhagic diathesis, or in cases of purpura, oil of turpentine 
is highly useful. Inhalations, by the atomizer, or spray douche, of a 
solution of Monsel's salt (subsulphate of iron) or the chloride of iron, 
will sometimes arrest a violent haemorrhage at once. This undoubted 
fact is all the more difficult of explanation, since but little, very little, 
of the iron salt can pass the chink of the glottis, and none of it can 
reach the point of disease in the lung. Tannin in solution may be em- 



HYPEREMIA AND (EDEMA OF THE LUNGS. 



433 



ployed in tlie same way, but the iron spray is distinctly better. In 
administering iron spray great care must be exercised to protect the 
teeth and the clothing, which may be permanently stained. A mouth- 
ful of common salt is a domestic remedy, which may be used until more 
efficient means are available. Counter-irritants are serviceable. A 
mustard-plaster or a flying-blister is sufficiently active, or a turpentine 
liniment, the latter being useful also because of its vajitor. Good re- 
sults may be obtained by inhalation of the vapor of turpentine disen- 
gaged for this purpose in those cases appropriate for its internal ad- 
ministration. If the haemorrhage has shown a disposition to recur, the 
recumbent position, quietude of mind, and the remedies employed to 
check it, if not objectionable, should be continued until all possibility 
of danger has passed. 



HYPEREMIA AND CEDEMA OF THE LUNGS. 

Definition. — HypercBmia signifies an abnormal increase in the bloods 
supply, which may be active or passive. (Edema is usually a conse- 
quence of hyperssmia, but it may be due to causes producing general 
oedema. The term signifies the presence of serous fluid in the alveoli, 
the intervening connective tissue, the perivascular lymph-spaces, etc. 

Causes. — There may be an increase in the amount of blood going 
to the lungs, the result of increased pressure in the arterial system, 
from greater force of the heart's contractions, or from narrowing of 
the arterial field elsewhere, throwing an additional quantity on the 
lung. Undue exercise of the vocal apparatus in speaking or singing, 
the inhalation of cold, or very warm air, or the sudden transition from 
one extreme of temperature to the other, and the inhalation of irritat- 
ing gases or vapors, are causes determining congestion of the lungs 
under favoring circumstances. The form and character of the chest 
and the existence of a constitutional vice or dyscrasia are necessary to 
bring about the results from the operation of such causes, especially 
the type of chest and the bodily conformation of phthisical subjects. 
The ingestion of cold drinks, the body in a warm and perspiring state, 
will sometimes induce extreme congestion of the lungs. The sudden 
impact of cold air or cold water on the surface will more surely pro- 
duce the same result, since a larger surface of the capillaries is made 
to contract, forcing the blood within. One part of the lung, the seat 
of a disease obstructing the circulation in it, will necessarily throw on 
another part an excess in its supply ; pneumonia, atelectasis, and obstruc- 
tion in some branches of the pulmonary artery, are examples. Pas- 
sive congestion is produced by causes interfering with the return of 
blood from the lung ; mitral stenosis and insufficiency, aortic stenosis 
and insufficiency, and obstructive lesions maintaining venous stasis, are 
examples. A weak heart may produce the same result by insufficiency 



434 



DISEASES OF THE RESPIRATORY ORGANS. 



in propulsive power, and hypostatic congestion results from such a state 
of adynamia that the blood simply obeys the force of gravity. (Edema 
is a result of congestion, whether active or passive, or a local effect of 
the causes producing a general dropsy. 

Pathological Anatomy. —When the lung is congested it is heavier, 
contains less air and more blood, and crepitates less than is normal. 
The color is darker and redder ; on section it is found to contain more 
fluid in the interstices, more blood flows out from the divided vessels, 
and the bronchi are injected and filled with a sanguinolent, frothy 
serum. In chronic cases the congestion is considerable, the color of 
the affected portions is dark red, almost blackish red ; the interstitial 
connective tissue is distended with serum, the capillaries are so swol- 
len as to compress the alveoli, almost or quite obliterating the cavity, 
and numerous extravasations are found through the parenchyma. So 
firm and dark becomes the tissue of the lung as to resemble the appear- 
ance of the spleen, whence the term splenization to characterize this 
condition. In the dependent portions of the lungs of the very adynam- 
ic or of aged persons confined to a recumbent position, a serous fluid, 
having considerable viscidity, exudes, giving to the lung on section a 
somewhat granular aspect, whence the term hypostatic pneumonia. 
In cedema there is a serous infiltration into the interstitial connective 
tissue and in the alveoli, which may be sufficient to distend the lung 
and afford pitting on pressure. On section of the lung under these 
circumstances, a quantity of serum flows out ; the serum is reddish 
when there is much congestion associated with the oedema. When 
oedema of the lung coexists with general dropsy, the fluid that exudes 
is colorless, and the tissue of the lung is pale. The dependent and 
inferior portions of the lungs first become oedematous ; thence it spreads 
to the superior and anterior portions as the fluid increases in amount. 
As a result of congestion of the passive kind, due to disease of the 
mitral valve, the lungs generally become denser, more resistant, and 
are much increased in size. The color, externally, varies from a red- 
dish-yellow to a brown, and on section its texture is found to be firm, to 
crepitate but little, to exude blood very freely, and not only blood, 
but, on pressure, to exude a yellowish or brownish fluid. While the 
general color of the divided surface is yellowish-red or brownish-yel- 
low, there are spots interspersed having a brownish almost blackish 
color — whence the designation hrown induration. Some of these brown 
spots are very dense, and sink in water. 

Symptoms. — A sudden and complete congestion of both lungs may 
be a cause of sudden death. Between this extreme and a simple uni- 
lateral congestion of slight extent, there are numerous gradations in the 
severity of the seizures. In the mildest cases there occur a sense of 
internal heat, oppression of the chest, some slight difficulty of breath- 
ing, a flushed face, a strong, full pulse, beating of the carotids, and in- 



HYPEREMIA AND (EDEMA OF THE LUNGS. 



435 



jection and brilliancy of the eyes. When the congestion is sufficient 
to cause universal oedema of the alveoli, the symptoms are formidable. 
There are great difficulty and extreme rapidity of breathing, a strong 
sense of oppression, intense anxiety, rapid and violent action of the 
heart, beating carotids and pulsation in the temples, headache and 
fnllness of the head, a flushed face, a hasty and troubled cough, and 
expectoration of a frothy liquid which may be tinted with blood. 

On percussion the resonance of the lungs is but little altered — 
slightly diminished, with a tympanitic quality. The vesicular murmur 
is supplanted by sub-crepitant and mucous rales, which are very abun- 
dant and very loud. If the alveoli are filled wuth fluid, the sonority 
will be still more diminished, and the respiration will have a blow^ing 
character approaching bronchophony. If the alveoli are filled to that 
degree that the oxygen can not reach the blood, accumulation of car- 
bonic acid must take place, and hence there will be blue lips, a livid 
face, headache, etc. When this condition is reached, there will be still 
greater anxiety and oppression, the breathing will be shallow and ex- 
ceedingly hurried, the pulse will decline in volume, and at length wdll 
be merely thready and intermittent, the surface of the body will be 
cold and covered with a clammy sweat, the fingers will be blue and 
cold, and with the accumulation of carbonic acid there will be in- 
creasing somnolence, replacing the extreme restlessness, deepening 
into coma. With the increasing stupor there will be less and less 
effort at cough and expulsion of the fluid accumulating in the bronchi, 
and an increasing difficulty of breathing from this cause. In the cases 
of passive congestion of the lungs, due to cardiac disease, there are 
difficulty of breathing, cough and oppression, constantly present, and 
paroxysms of extreme dyspnoea, in which the patient labors for breath, 
the face is cyanosed, the extremities cold and blue, the skin cold and 
covered with a clammy sweat, the pulse, small, weak, and irregular, 
the jugulars sw^ollen, the mind clouded, etc. The severity of these 
attacks will be greatly increased if oedema come on suddenly ; but if 
the oedema is gradual in forming, the difficulties of breathing will be 
slowly augmented, and carbonic-acid poisoning will also be slowly de- 
veloped. The physical signs in cases of hypostatic congestion w^ill 
indicate the existence of bilateral lesions if the decubitus is dorsal ; or 
unilateral, if the decubitus is to one side. The sonority is diminished, 
or dullness with a tympanitic quality exists. On auscultation, the ve- 
sicular murmur will be weak, or supplanted by moist rales. The dif- 
ficulty of breathing which arises during chronic Bright's disease is due 
to oedema of the bronchial mucous membrane — an interstitial oedema 
and swelling of the terminal bronchi. 

Course, Duration, and Termination. — An acute congestion of the 
lungs may pass through its whole course and prove fatal within a few 
hours. The usual duration is from three to five days, and the termi- 



436 



DISEASES OF THE RESPIRATORY ORGANS. 



nation may be by resolution, occasionally by haemorrhage, and rarely 
by inflammation or pneumonia. The passive form associated with 
cardiac disease develops slowly, and is subjected to great variations ; 
to periods of improvement under appropriate treatment ; then exacer- 
bations. Acute oedema may come on, and prove quickly fatal in acute, 
or chronic kidney affections. 

Diagnosis. — Active congestion is to be distinguished from the stage 
of engorgement in pneumonia. The points of difference are : in 
congestion there are no chill, no pain in the side, and not the range 
of temperature of pneumonia. The subsequent course separates the 
two diseases more widely. (Edema occurring during hyperaemia is 
announced by dyspnoea, by the auscultatory signs of the presence of 
fluid in the terminal bronchi, and by the expectoration of a frothy, 
serous, and reddish fluid. The hyperaemia of a passive kind produced 
by valvular lesions is accompanied by rational and physical signs, 
which make the diagnosis merely a question of the recognition of 
these signs. 

Treatment. — Active congestion in a plethoric subject may demand 
bloodletting, if not by venesection, by the application of cups or 
leeches to the chest. A ligature to the thighs applied merely firmly 
enough to retain the blood in the superficial veins is a useful expedi- 
ent when the abstraction of blood may seem to be necessary. Coun- 
ter-irritation in the form of a large mustard-plaster should be applied 
to the chest, and the feet should be put in a hot foot-bath. As the 
removal of the fluid in the alveoli and terminal bronchi is of the 
utmost necessity, an active emetic should be prescribed ; of these 
apomorphine subcutaneously is probably the best, and next, the sub- 
sulphate of mercury. Stimulant expectorants should be prescribed 
to procure the expulsion of the fluid by expectoration. Squill, senega, 
and serpentaria are appropriate remedies for this purpose. To dimin- 
ish the viscidity of the fluid, and thus secure its easy expulsion, the 
iodides, especially the iodide of ammonium, are highly serviceable. The 
iodide and carbonate of ammonium in sirup of senega is an excellent 
combination to secure the rapid and easy extrusion of the fluid pres- 
ent. In the oedema of cardiac disease and renal dropsy, digitalis and 
squill are very important remedies. If the blood is much impover- 
ished, iron is indicated, especially the iodide of iron, which is a rapidly 
acting and an efficient chalybeate. When there is hypostatic conges- 
tion, changes in the position of the patient are very necessary, and 
the propulsive power of the heart must be increased by stimulants, 
quinine, and small doses of opium. In the cases of brown induration, 
the iodide and carbonate of ammonium should be persistently used 
together, with means to increase the energy of the heart, such as tur- 
pentine, eucalyptol, and alcoholic stimulants. 



ATELECTASIS. 



ATELECTASIS. 

DefiLition. — This term means a collapse of the lobules, so that the 
cavity disappears and the walls approximate. Congenital atelectasis 
is the state in which the lungs are before being dilated with air (foetal 
lung). 

Causes. — The congenital condition is simply a failure to distend 
the alveoli. The whole lung may be in such a state, or only a part of 
it, in a premature child, or one so weak at full term as to be unable 
to expand the lungs fully, and hence some of the lobules or alveoli 
remain in a state of atelectasis. The acquired atelectasis is the col- 
lapse of lobules that have been expanded. A terminal bronchus may 
be closed against the admission of air by a plug of mucus which, act- 
ing like a ball-valve, permits the exit, but not the entrance, of air, so 
that gradually all the residual air is expelled, and then the sides 
approximate, and the cavity is closed — in other words, it has col- 
lapsed. This result is the more apt to occur in the case of feeble, 
ill-nourished, and ill-developed children, who are attacked with such 
troubles as measles, whooping-cough, etc. Collapse of lobules — of a 
large part of a lung, indeed — may be induced by pressure on a bron- 
chus, of an aneurism, of enlarged bronchial glands, tumors, etc. The 
air remaining in lobules, to which the access of air is cut off, is 
gradually absorbed by the blood. Direct pressure may also cause 
atelectasis — such direct pressure as is made by hydrothorax, empy- 
ema, hydropericardium, aneurisms, tumors of the thorax, and effu- 
sions in the peritoneal cavity, sufficient to push up the diaphragm. 

Pathological Anatomy. — Seen from without, those portions of the 
lung in the atelectatic condition have a bluish-red color, or grayish, 
and are depressed somewhat below the general surface of the organ. 
These parts have a greater density than the healthy tissue, and, as 
they do not contain air, do not crepitate on pressure, and they are 
tough and not easily broken up. When divided, but little blood 
flows out, nor do they contain any kind of fluid, and appear smooth 
instead of granular. When inflated with air, as freshly atelectatic lung 
can be, an immediate change in color ensues, the lobules become pink, 
and crepitate on pressure as normal lung. If, however, they contin- 
ued collapsed, changes of a nutritional kind ensue, and, after a time, 
dilatation can not be effected. When congenital, this condition is 
found to exist in the posterior and inferior parts of the lungs, in the 
apices and anterior borders, and may be limited to individual lobules, 
or a considerable part of a lobe may be affected. When atelectasis is 
acquired, usually isolated lobules, or small groups of lobules, are thus 
affected, they are more or less thickly disseminated through both lungs, 
and the superficial portions are first attacked, the deeper parts subse- 
quently. This acquired atelectasis differs from the other in that the 



438 



DISEASES OF THE RESPIRATORY ORGANS. 



collapsed parts contain more blood and serum, and hence there is a 
marked difference in appearance of the affected and surrounding 
surfaces, since the latter are distended with air, and paler ; are, in 
fact, in the condition of vicarious emphysema. The pleura is usu- 
ally normal ; it may be somewhat congested and thickened. The 
situation of the collapsed lobules is due to the position of the com- 
pressing force. If the force of the compression has not been suffi- 
cient to drive all the blood and air out, it is then said to be carnijied ) 
if all blood and air are excluded, the color is grayish, and the tex^ 
ture is firm. 

Symptoms. — In congenital atelectasis, symptoms are produced only 
in the event that a considerable number of lobules are collapsed, when 
the chief sign is imperfect respiration. The thorax has but little am- 
plitude of movement, the breathing is rapid but superficial, and the 
voice is nothing more than a husky whisper. So rapid is the breath- 
ing, and urgent the need of air, that a child so affected nurses with 
difficulty, or not at all. The supply of oxygen being inadequate, car- 
bonic acid accumulates ; the lips are blue, the extremities blue and 
cold, and very feeble, and there are drowsiness, muscular twitchings, 
and possibly convulsions and paralysis. In the acquired form, the 
collapse of the lobules is preceded by bronchitis of the finer tubes. 
When the atelectasis occurs, the difficulty of breathing increases, there 
is corresponding frequency, and the movements of the two sides may 
be unequal if there be a limitation to one lung. In inspiration, instead 
of expansion of the chest in all directions, there is retraction of the 
intercostal spaces, and of the inferior ribs, due to the fact that the 
lungs can not be expanded. The significance of the physical signs 
will depend on the extent to which the atelectasis has proceeded. If 
isolated lobules only collapse here and there, and the adjacent lobules 
are dilated (vicarious emphysema), there will be no appreciable change 
in the sonority. If, however, a group may be collapsed of consider- 
able extent, there will be dullness, but the note will have somewhat 
the tympanitic quality. The changes on auscultation will depend 
equally on the amount of tissue in the condition of collapse. The re- 
spiratory murmur will be replaced by bronchial sounds if there are 
a large number of lobules atelectatic. These sounds will also change 
with the alterations in the affected parts — an increase of the collapse 
will enlarge the area of dullness ; improvement in the local condition 
and the reentrance of air will reproduce the vesicular murmur. As 
very pronounced lesions are associated with the atelectasis, obviously 
the symptomatology will be very much influenced by them. An im- 
portant complication arises from the collapse of lobules : the pulmo- 
nary circulation is obstructed, the blood accumulates on the right side, 
the cavities dilate, the venous system is abnormally full, and the ar- 
terial system is ischsemic. The results of this state of things are, there- 



ATELECTASIS. 



439 



fore venous stasis and cedema, the pulse is small, the urine scanty and 
high-colored, and the skin pale and relaxed. 

Course, Duration, and Termination. — The course of atelectasis is 
that of the malady associated with it. The congenital form, if limited 
in extent and not associated with a patulous condition of the foramen 
ovale, may get well. If, however, it is extensive, and especially if the 
cardiac anomaly exist, life will continue feebly for a short period, and 
death occur, frequently in convulsions. The acquired condition, when 
associated with capillary bronchitis and catarrhal pneumonia, pursues 
two directions : imperfect recovery with damaged lungs, these organs 
becoming emphysematous ; caseous pneumonia and phthisis. The du- 
ration, therefore, becomes indefinite, and the termination that of the 
associated disease. Acute cases terminating fatally rarely continue 
longer than one week. 

Diagnosis. — Atelectasis is to be distinguished from bronchitis, 
pneumonia, and effusions in the thorax. As atelectasis is usually as- 
sociated with bronchitis, the distinction will rest on the evidences of 
consolidation of the lung, which are not present in bronchitis. There 
are no real differences between atelectasis and catarrhal pneumonia, 
since atelectasis occurs more or less in the former ; hence the distinc- 
tion must rest on the course and behavior, on the locality, and the 
difficulty of breathing with retraction of the ribs, which occurs in 
atelectasis and not in catarrhal pneumonia. From croupous pneumo- 
nia atelectasis is distinguished by these symptoms, which are peculiar 
to pneumonia : localized pain, initial chill, high temperature, crepitant 
rdles, crisis — and do not occur in atelectasis. 

Treatment. — In the congenital disease, the child should be made to 
cry vigorously, or the lungs should be well expanded by an efficient 
and careful inflation with condensed air — an ordinary-fire bellows will 
suffice. The chest should be irritated with mustard and tincture of 
iodine, the great delicacy of an infant's skin being regarded. Re- 
spiratory stimulants are very useful. Belladonna stands first, next 
strychnia. Suitable nourishment must be given, and stimulants should 
also be freely but carefully administered. In the treatment of the 
acquired disease, the accompanying bronchitis is the point to which 
attention must be directed. The author has witnessed such important 
results from the use of iodide and carbonate of ammonium, that he 
must repeat his recommendation of them. They should be given in 
small doses frequently repeated. By increasing the flow of serum and 
lessening the viscidity of the tough secretion which occludes the ter- 
minal bronchi, the access of air is again secured to the alveoli. Stim- 
ulants to the respiratory function are equally necessary as in the con- 
genital form. Belladonna, or, preferably, atropia (^-^q- grain ter in 
die), turpentine, eucalyptol, copaiba, are very valuable remedies for 
this purpose. If the symptoms are urgent, emetics must be used to 



440 



DISEASES OF THE RESPIRATORY ORGANS. 



clear the tubes, of which the most effective are apomorphine, subsul- 
phate of mercury, and ipecac. If the strength is reduced, or if the 
disorder has occurred in a strumous or rachitic subject, quinine, arsenic, 
iron (syrup, ferri iodidi, 3 j ter in die), and cod-liver oil, are very ne- 
cessary and useful. Inhalations of compressed air should be practiced 
as soon as the condition of the patient will warrant it. Inhalations of 
turpentine-fumes, and of the vapor of iodine or ethyl iodide, are very 
efficient in removing lingering bronchial lesions. 

EMPHYSEMA OF THE LUNGS. 

Definition. — As emphysema means an infiltration of the connective 
tissue with air, certain adjectives are necessary to define the position. 
Pulmonary emphysema is the form of disease meant here. A general 
emphysema of the connective tissue of the body is produced when a 
fractured rib, puncturing the lung, permits the air to pass through the 
injured pleura into the connective tissue. The subject of pulmonary 
emphysema has been much confused by the variety of terms employed 
in explanation of the characteristics of the disease. There are two 
varieties, as regards the part of the lung affected : the vesicular and 
the interlobular ; the former meaning alveolar emphyseraa, the latter 
meaning the presence of air in the space between the lobules of the 
lungs and underneath the pulmonary pleura, whence the terms inter- 
lohiilar emphysema, suh-pleural emphysema. When the disease occurs 
as an idiopathic and independent malady, it is known as substantive 
emphysema ; when developed because of another malady, as, for ex- 
ample, the dilatation of the alveoli which occurs because of atelectasis, 
it is known as vicarious emphysema. 

Causes. — There is a type of lung, transmitted by heredity, which 
is peculiarly liable to emphysema. The alveoli are relatively too 
large and their walls thin ; the connective tissue too largely devel- 
oped ; the vascular supply is insufficient ; the chest is deep, and the 
heart lies lower than is normal ; and the muscles of respiration are thin 
and rather weak. Males are more liable than females, because more 
exposed to the conditions exciting the malady. It is said, but this 
statement must be regarded as doubtful, that musicians blowing wind- 
instruments are apt to suffer from it. Various injuries and diseases 
of the chest which limit the movements of the lungs, as curvature of 
the spine, pleural adhesions, hydrothorax, tumors, etc., are supposed to 
produce it. Vicarious emphysema is especially due to attacks of ^ 
capillary bronchitis and atelectasis in youth and early manhood, or 
succeeds to whooping-cough and measles for the same reason that 
bronchitis has led to collapse of lobules, and consequent emphysema 
of those not collapsed. All of the causes and conditions producing 
capillary bronchitis are therefore concerned in the production of em- 



EMPIIYSEilA OF THE LUNGS. 



441 



physema. Interlobular and sub pleural emphysema are caused by rup- 
ture of acini, usually by such mechanical violence as severe coughing, 
but there is necessary to this result probably a weakness of the part 
yielding to such force. Various theories have been proposed to ac- 
count for the production of emphysema : they may be referred to two 
groups — inspiratory and expiratory. As, however, original faulty 
structure may exist, emphysema is produced in such by causes which 
would not affect healthy lungs. This form or type of structure, which 
is distinctly hereditary, has been referred to above. In addition to 
these changes, Freund explains the production of emphysema by a 
theory which supposes the thorax to be in a condition of fixed dilata- 
tion by alterations in the costal cartilages. Although this state of 
the thorax may sometimes be a cause of emphysema, .it can not be so 
frequently. That the original faulty structure is an important factor 
in the production of emphysema is certainly true ; but that the respi- 
ratory acts of inspiration and expiration have also much influence can 
not be doubted. A certion proportion of cases of vicarious emphysema 
are explained by Williams's theory of negative inspiratory pressure y 
that is, the alveoli appended to unobstructed bronchi dilate in conse- 
quence of the increased pressure due to the obstruction and disuse of 
many tubes. If there exist an hereditary change in the structure of the 
alveoli, this increased pressure causes them to yield permanently and 
lose their elasticity. If the inspiratory pressure is thus increased, i. e., 
by the obstruction to many bronchi throwing a larger volume of air 
and higher pressure on those admitting air freely, and the expiratory 
pressure is lessened, there will occur emphysema by atrophy of the 
alveolar tissue — the theory of Niemeyer. A large proportion of cases 
are produced undoubtedly \)j forced expiration. In the act of cough- 
ing, the glottis being closed, the expiratory pressure is certainly very 
great, and all the more in the unobstructed lobules, because so many 
are closed and are in the atelectatic state, throwing the whole force of 
expiration on a less number of lobules. The result is that the alveoli 
yield in those parts of the chest not protected by bony walls, at the 
apex, and toward the root, at the anterior border, in those situations 
where the emphysematous condition is most decided. 

Pathological Anatomy. — Enlargement of the lungs is not always 
found as expected ; adhesions may prevent the anterior borders coming 
forward to the median line, or the lungs may be actually smaller than 
normal by the collapse of many lobules, the occurrence of interstitial 
pneumonia, and the contraction of the connective tissue. On the 
other hand, the lungs may fill up the thorax, cover the prsecordial 
space, depress the heart, and lengthen the thorax to the seventh rib 
by depression of the diaphragm. When the emphysematous lungs 
are removed from the thorax they do not collapse, and remain full, 
especially if the bronchi are swollen and filled with viscid mucus, 



442 



DISEASES OF THE RESPIRATORY ORGANS. 



which will prevent the egress of air. The situation of the emphy- 
sematous portions will depend on the form. In those cases due to 
heightened expiratory pressure, the force is expended on the apex and 
anterior border, and hence here will be found the characteristic 
changes. In vicarious emphysema, due especially to broncho-pneumo- 
nia, the altered portions will exist more widely — at the apex, the ante- 
rior border, and along the diaphragm, or they may be very irregularly 
distributed about the atelectatic points. The appearance of a lung 
affected with emphysema is peculiar : it is of a pale-red color, the en- 
larged lobules are little sacs or bladders, not larger than from the size 
of a pin's-head up to that of a pea, but by the breaking down of the 
septa between them a number may coalesce, forming a bladder the 
size of a walnut. When pressure is made, the elasticity of the lung 
is found to be so much impaired that the pits made disappear slowly 
or not at all. The tissue of the lung is also very dry and ansemic, and 
but little fluid of any kind exudes from it on section ; but there is 
much pigment deposited in small, localized collections, and traversing 
the atrophied tissue in lines, the remains of blood-vessels. On micro- 
scopical examination, the walls of the acini are found to be exceed- 
ingly thin and attenuated, the septa broken down so that the remains 
of them merely project into the infundibular area, or disappear en- 
tirely.* In some specimens, the intervening connective tissue becomes 
hypertrophied, so that the walls of the vesicles appear much thick- 
ened. In the progress of the atrophic change, the septa between the 
lobules breaking down, a number of acini are thus converted into a 
large one. The blood-vessels are from the beginning obstructed, the 
red corpuscles pass out by diapedesis, and, collected in groups, form 
the masses of pigment already mentioned, or the blood-globules re- 
tained by the arrest of the current and obliteration of the vessels in 
front form a fine tracery of pigment. The continued pressure sets 
up a rapid degeneration of the vessel-walls, and they ultimately disap- 
pear by absorption, whence it happens that the tissue is dry and blood- 
less. The obstruction to the pulmonary circulation is ultimately so 
great that the pulmonary artery and right cavities become greatly 
distended. Finally, the muscular tissue of the heart undergoes de- 
generation, granular and fatty. The distention of the veins leads to 
widespread venous stasis — nutmeg-liver, congested kidneys, and albu- 
minuria, gastro-intestinal hypersemia and catarrh, passive congestion 
of the brain, etc. 

Symptoms. — The usual history of cases of emphysema is the occur- 
rence of attacks of capillary bronchitis, catarrhal pneumonia, or at * 
least of severe bronchitis at some period in childhood, after which 
there exists a great susceptibility to colds and frequent attacks of 

* Thie-rf elder, " rathologisclie Histologic," 1. Lieferung, Tafel vi 



EMPHYSEMA OF THE LUNGS. 



443 



severe catarrh with difficulty of breathing. After puberty the diffi- 
culty of breathing is found to be more decided ; bronchial catarrh is 
not then a matter of cold weather and attacks of acute cold, but is 
constantly present. In other cases, after whooping-cough, or measles, 
a troublesome cough, bronchial catarrh, and shortness of breath come 
on, and steadily increase. If such attacks have occurred in youth, by 
the time of puberty the emphysema is pronounced, and the chest has 
assumed the peculiar " barrel-shape," characteristic of this disease. In 
still another group of cases, the onset is gradual, and the emphysema 
is the outgrowth of years of bronchial catarrh, the fully developed 
emphysema not being attained until the middle or after period of 
life. In which mode soever emphysema manifests itself, the diffi- 
culty of breathing is the most pronounced symptom. In all attempts 
at active exercise, mounting stairways, ascending heights, etc., the 
breathing is embarrassed. Even before the patient is conscious of his 
pulmonary defects in this direction, a good observer vrill note the fre- 
quency and imperfect expansion of the thorax. The shortness of 
breathing is dependent on several factors : the diminution in the num- 
ber of capillaries has an effect in this way by the lessening, which the 
loss of vessels involves, of the oxygenation of the blood, so that in- 
creasing frequency of respiration is compensatory of this deficiency. 
Again, depression of the diaphragm renders additional efforts on the 
part of the inspiratory muscles necessary, and hence this adds to the 
difficulty of carrying on respiration. More important than these is the 
loss of the elasticity of the lung, which requires that the muscles of 
expiration shall take up the labor of expelling the air, which they 
accomplish slowly and with great effort. This expiratory insuffi- 
ciency involves another difficulty — the residual air in the acini is not 
displaced, and hence can not furnish oxygen to the blood. The con- 
currence of these several factors produces the most obvious objective 
symptom in emphysema — the embarrassed respiration. Both inspira- 
tion and expiration are embarrassed ; all the muscles, auxiliary as well 
as ordinary, are engaged in inspiration and expiration, but the move- 
ments of the chest are very slight notwithstanding the labor, and a 
constant and distressing sense of the need of air is experienced ; the 
cervical muscles are rigid and prominent, the head erect and forward 
to permit the easy entrance of air and to facilitate the action of the 
muscles ; the shoulders elevated ; the veins of the neck enlarged and 
dilated, and the face more or less cyanosed. A peculiar configuration 
of the chest is brought about by emphysema, which has existed for 
some time in young subjects. The chest becomes round ; the inter- 
costal spaces wider ; the vertical diameter elongated. As the emphy- 
sema may be limited to one part, the changes in the shape of the 
chest will correspond. The departure from the normal consists in a 
circumscribed prominence more frequently on the left than the right 



DISEASES OF THE RESPIRATORY ORGANS. 



side ; above the clavicle, or between the clavicle and nipple, or, during 
coughing, the lung pushes the parietes of the chest forward at these 
points, producing a soft, elastic, and resonant swelling. The physical 
signs are very instructive. On inspection, the character of the respira- 
tion, the movements of the accessory muscles, and the extremely small 
excursions of the thorax in breathing are readily ascertained. On pal- 
pation, the vocal fremitus is diminished, the apical impulse is feeble, 
and the epigastric pulsations are increased. The heart is found to 
lie lower down than in the normal thorax, and the liver is also pushed 
lower, both due to the enlargement of the lungs in the vertical diam- 
eter. On percussion, the sonority is increased over all the emphysema- 
tous portions, and, when the whole lung is involved, extends down to 
the seventh or eighth rib in front, and behind to the twelfth rib in 
extreme cases. The hepatic dullness may not begin until the inferior 
margin of the ribs is reached, and even when hypertrophy exists the 
area of cardiac dullness is much narrowed and may not exist at all 
when the emphysema is extreme. On auscultation over all parts re- 
turning a resonant percussion-note, the vesicular murmur is weakened, 
and may entirely disappear over the lungs ; and the bronchial sounds, 
which are audible at the root of the lungs posteriorly in the normal 
state, may also disappear. In other cases, the vesicular murmur, 
whether enfeebled or not, is changed in character ; on inspiration it 
becomes rough, rude, sibilant or crackling, due to the entrance of air 
into the dilated and inelastic lobules, and expiration is prolonged and 
rough from the same cause. Expiration is usually inaudible, but an 
expiratory sound may be due to an accompanying bronchitis, to nar- 
rowing of the bronchioles by swelling of the mucous membrane, 
whence the sound has a rather sibilant character. The accompanying 
bronchitis, which is usually quite extensive, produces various moist 
sounds — sub-crepitant, mucous, and sub-mucous rales, which are not 
necessary to emphysema. The sounds of the heart audible in the 
mitral and aortic area are in emphysema less distinct than in the nor- 
mal state, while in the pulmonary and tricuspid area they are well 
defined, the pulmonary second sound being sharply accentuated. 

Course, Duration, and Termination. — Emphysema is an essentially 
chronic malady. Beginning often years before any great difficulty of 
breathing is manifest, it pursues a course which in its mildest form 
may continue during an ordinary lifetime. The least extensive cases 
may continue with little interference in the duties of life for many 
years, but the position is far different with those examples of emphy- 
sema occupying a large part of both lungs. In a pronounced case, 
beginning in one of the modes already described, there are constant 
difficulty of breathing, and cough and expectoration due to an attend- 
ant bronchitis. On taking a bronchial cold, to which they are ex- 
tremely liable, or on making some sudden muscular effort, the diffi- 



EMPHYSEMA OF THE LUXGS. 



445 



culty of breathing is greatly increased, they labor to get breath, are 
blue in the face, sweating with their exertions, and unable to lie down. 
After some hours, or a day or two, the paroxysm subsides, and they 
are back again in the former condition, except each attack increases a 
little the existing mischief, the breathing is a little more embarrassed, 
and there are more cough and expectoration. The paroxysms of asth- 
matic difficulty of breathing increase in number and frequency, until 
after some years there is no period of partial relief. Meanwhile, the 
obstacles to the pulmonary circulation increase : dilatation of the right 
cavities of the heart and stasis in the venous system occur ; the liver 
swells with venous hypersemia ; the gastro-intestinal mucous mem- 
brane also is hypersemic, and is affected with catarrh ; the liver is 
congested, and the urine becomes albuminous. General dropsy now 
comes on, fluid accumulates in the peritoneal cavity also, but to a less 
extent in the pleura. The presence of fluid in the two cavities adds 
to the difficulty of respiration, and now the patient can get breath 
only as he sits up, leaning somewhat forward. This position increases 
the accumulation of fluid in the legs, which become blue, cold, and 
very painful ; the skin yields, blisters form, and, giving way, an ulcer 
is established from which serum continuously exudes. Such is the 
course of a well-defined case. Although all are not so severe, yet 
when emphysema occurs in an adult it is a permanent condition. It 
is probable that a slight amount of emphysema in a child may get 
well, but usually the first changes in childhood are the initial of a long 
series, and continue. Death may be due to the rupture of some of the 
dilated cells and the formation of an extensive interlobular and sub- 
pleural emphysema. The termination is often by some intercurrent 
disease, as catarrhal or croupous pneumonia, cerebral haemorrhage, or 
paralysis of the heart. Xot with standing the unpromising nature of 
the disease, all do not proceed regularly from bad to worse. Periods 
of improvement may take place, and the difficulty of breathing almost 
disappears, to return again, however, on the occurrence of a bronchial 
attack or some other disturbance. The cases are, as a rule, more se- 
vere in winter than in summer. 

Diagnosis. — The diseases with which emphysema may be con- 
founded are bronchitis, bronchial asthma, catarrhal pneumonia, pneu- 
mothorax, aneurism of the arch of the aorta, and cardiac diseases, with 
spasmodic difficulty of breathing. From bronchitis, it is distinguished 
by the presence of those signs characteristic of emphysema, as diffi- 
culty of breathing, increased sonority of the chest, changes in the 
shape and size of the thorax, and by the disturbances of the circula- 
tion and dropsy ; from bronchial or spasmodic asthma, by the fact 
that in the latter there are no alterations of the chest, and the diffi- 
culty of breathing is occasional and spasmodic entirely ; from catar- 
rhal pneumonia, by the history, by the localization of the affection, by 



446 



DISEASES OF THE RESPIRATORY ORGANS. 



the changes in the chest, and by the subsequent course ; from pneu- 
mothorax, by these considerations : pneumothorax is sudden, almost 
always unilateral, the chest much distended, the intercostal spaces 
prominent, the heart is displaced to the other side, succussion is pres- 
ent if there is fluid, which is usually the case. In aneurism there is 
dullness instead of increased sonority over the site of the aneurism, 
and no change elsewhere, and the difficulty of breathing is due to pa- 
ralysis of the vocal cord, which may be seen, and to pressure on nerve- 
trunks. In heart-disease the area of dullness is not only present but 
usually increased, and the apex-beat is normal or increased, while the 
form of the chest and the sonority are not affected. 

Treatment. — As we have to deal with an incurable disease, our 
treatment must be largely palliative. For the asthmatic attacks there 
is no remedy so efficient as the subcutaneous injection of morphine and 
atropine (-j- morphine and yto atropine). Care must be exercised lest the 
morphine-habit be formed, as it is apt to be under these circumstances, 
and hence the injections should always be practiced by the physi- 
cian, and reserved for occasions of great distress. A single injec- 
tion may arrest a paroxysm, but the dose may be repeated as neces- 
sary, rarely more frequently than once in six hours. Next to the 
injection of morphine, most relief is afforded by full doses of iodide of 
potassium alone, or combined with the bromide. From fifteen to 
twenty grains of the iodide, and forty grains of the bromide, every 
two, three, or four hours, according to the urgency, may be prescribed. 
Chloral, which affords great relief, is very unsafe in old cases with 
dilated right cavities ; if given under any circumstances, it should be 
combined with morphine and atropine to prevent the depressing effect 
on the heart. A combination of morphine, chloral, and atropine is an 
exceedingly serviceable combination for the relief of the difficult breath- 
ing. Besides these agents, narcotic fumigation may be practiced. Pas- 
tils of belladonna, stramonium, tobacco, opium, eucalyptus, etc., may be 
burned, and the fumes inhaled. Such pastils are always much used by 
these sufferers, since they procure in this way ready and considerable 
relief. Inhalation of ethyl iodide is a measure of great utility, and is 
free from danger. As the accompanying bronchitis is an important 
element in these cases, measures are necessary to relieve it. The best 
results are obtained from copaiba, turpentine, and eucalyptol, given in 
conjunction with the iodide of ammonium. Excellent results are ob- 
tained from the combined administration of iodide of ammonium and 
arsenic, continued for some time. It is well known that arsenic increases 
the depth and volume of the respiration and promotes the nutrition of 
the lung, and the iodide is an effective remedy for the bronchitis. In 
these facts we have an explanation of the utility of the combination. 
When the bronchial secretions are insufficient, small doses of tartrate 
of antimony are very useful, and give great relief. Quebracho, 
which has lately been brought forward as a remedy for dyspnoea, 



EMPHYSEMA OF THE LUNGS. 



U7 



is a valuable palliative. Atropine is a remedy of great power, and has 
an influence over the lung, increasing the respiration and promoting 
the nutrition of the organ. It may distress if there is a lack of bron- 
chial secretion, but usually the opposite state obtains, and consequently 
atropine can be given, as it ought to be, under these circumstances, in 
small doses twice a day for a long period. Of all the means hitherto 
proposed for the relief of emphysema, nothing has approached com- 
pressed air in effectiveness. Indeed, this is the only scientific remedy 
which has as yet been brought forward for the treatment of emphy- 
sema. The chamber into which air is pumped until a pressure of one 
and a half to two atmospheres is obtained is the best arrangement, 
but unfortunately they are available but in a few places. The port- 
able apparatus of Waldenburg is convenient, easily managed, and pro- 
duces good results. The object of compressed air is to relieve the 
breathing by supplying more oxygen, and it effects an equalization of 
the blood in the two systems by redistributing the pressure. By re- 
tarding the breathing and the action of the heart, the contractions are 
firmer, and the cavities are better emptied. The improved condition 
of the blood, the result of a better supply of oxygen and increased 
excretion of carbonic acid, induces a better state of digestion and as- 
similation. By breathing compressed air, the pressure is transferred 
from the venous to the arterial system, and while the amount of blood 
on the right side is diminished, on the left it is increased. The good 
effects of breathing compressed air are enhanced by expiration into 
rarefied air, which of course has the effect to draw the blood into the 
lungs. " Expiration into rarefied air is the specific mechanical anti- 
dote to emphysema." * The inhalation of compressed air or of oxy- 
gen may be used as a palliative to relieve the attacks of spasmodic 
difficulty of breathing. 

The treatment of the dropsy requires a nice adjustment of means to 
the object. Much can be accomplished by acting on the skin and kid- 
neys. If the heart will bear it, pilocarpine may be employed to act on 
the skin. Hydragogue cathartics can be given at the same time, of 
which the pulv. jalapse comp. is best. A teaspoonful or two should be 
taken in the early morning, and pilocarpine in the afternoon. If the 
desired results can not be thus attained, free diuresis may be attempted 
while the hydragogue is also administered. Basham's mixture is an 
excellent combination, containing as it does a chalybeate with a saline. 
Memeyer's prescription of vinegar of squill, with bicarbonate of potas- 
sa — thus forming acetate of potassa — is a good diuretic. There is no 
more certain diuretic than bitartrate of potassa, and it may be com- 
bined with infusion of juniper and squill. A weak solution of cream 
of tartar may be drunk ad libitum. Infusion of digitalis may also be 

* " Die pneumatische Behandlung," etc., Dr. L. Waldenburg, Hirschwald, Berlin, 1875, 
p. 302. 



448 



DISEASES OF THE RESPIRATORY ORGANS. 



1 



given ; but as so mucli obstruction exists in tbe lung, and as there is also 
ischaemia of the arterial system, its use is doubtful. 

GANGRENE OF THE LUNG. 

Definition. — Gangrene is the same morbid process, whether occur- 
ring in the lung or elsewhere. Gangrene of the lung, therefore, means 
the death and decomposition of a greater or less portion of the lung- 
tissue. 

Causes. — Sex exercises an important influence, since somewhat more 
than two thirds of the cases occur in men. Although it may happen at 
any age, it is more common from puberty to middle life. A lowered 
condition of the vital forces, such as is produced by abject poverty and 
its attendant miseries, seems necessary to the result. Interruptions to 
the blood-supply, as elsewhere, may induce gangrene. Thus it occurs 
in cases of pneumonia, hsemorrhagic infarctions, catarrhal pneumonia, 
etc. ; but a depressed bodily state is necessary, such as exists in drunk- 
ards who are ill fed and exposed to cold and wet. Gangrene may be 
due to the so-called blood-diseases — as typhus, diabetes, small-pox, 
measles, etc. — but a low state of the tissues or a depressing cachexia 
must coincide, the lung becoming the seat of the morbid process be- 
cause invited by a local malady, such as pneumonia. The deposit in 
the lung of septic and decomposing materials, as septic or infective 
emboli, will set up a destructive inflammation terminating in gangrene. 
Putrefactive decomposition in the neighborhood of the lungs, the 
penetration of the organ by cancer-masses, or the lodgment of foreign 
bodies, may give rise to a gangrenous inflammation. Lastly, gangrene 
may be due to traumatism, or to penetrating wounds of the chest. 

Pathological Anatomy. — Gangrene may attack any part of the lung, 
but the upper lobe is more often the seat of it than the inferior. It 
occurs in two forms, of circumscribed, of diffused — the former being 
well defined and strictly limited, the other not separated by any defined 
border, but spreading into the surrounding lung-tissue. The circum- 
scribed form attacks by preference the outer portion of the lung, and 
may or may not include the pleura. There may be several of the gan- 
grenous spots, which vary in size from a pea to an orange, or even 
larger, and they occur rather more frequently in the right lung. The 
borders are clearly marked, the surrounding tissue being hepatized or 
oedematous. According to the time at Avhich the masses are examined, 
they are firm, dry, almost black or soft, diffluent, greenish, or brown- 
ish, decomposing and offensive masses traversed by large vessels not 
destroyed, and by bronchi, opened by ulceration, through which the 
liquid and softened debris are discharging. Gradually sloughing off 
after evacuation by the bronchi, there may be an attempt at repair, 
the spread of the decomposition being prevented by the formation of 



GANGRENE OF THE LUNG. 



449 



a dense, tough, and rather hyperjemic connective-tissue membrane. A 
complete recovery can only occur when the gangrenous mass is small 
and communicates with a small bronchus. The membrane lining the 
cavity, formed as just described, pours out a quantity of ichorous pus, 
which serves to spread the morbid process. When the cavity is small 
enough to close and heal, granulations are thrown out, the walls ap- 
proximate, and healing takes place, a cicatrix remaining. The ichor- 
ous pus poured out from the so-called pyogenic membrane sets up a 
destructive inflammation of the bronchial mucous membrane, which 
softens and is detached, and excites attacks in the dependent parts of 
the lungs of broncho-pneumonia, which pursue the same course. If 
situated at the periphery of the lung the softening may involve the 
pleura, and the decomposing materials be discharged into the pleural 
cavity, exciting a violent pleuritis and a pyopneumothorax, if a bron- 
chus is at the same time opened. It is a remarkable fact that a limit- 
ing pleuritis may confine the inflammation to a small extent of the 
membrane, perforation of the thorax ultimately ensue, with a termina- 
tion in recovery. In a few cases the pus has dissected downward along 
the sheath of the psoas muscle and opened externally at the groin. 
The diffused form may, as has been shown, arise from the circum- 
scribed by an extension of the morbid process through the distribution 
of the ichorous pus from a gangrene cavity. But the diffused form 
usually has its origin in an inflammation proceeding from a gangrenous 
cavity, or from a case of purulent infiltration of pneumonia. The tis- 
sue affected with the gangrenous inflammation rapidly breaks up into 
shreds of decomposing materials, infiltrated with a brownish or black- 
ish fetid fluid, and the morbid process spreads into the surrounding 
tissue, hepatized and cedematous, without any defined boundary. In a 
short time much of the upper lobe may be in a gangrenous state, and 
the whole of it, indeed, may be involved. In both forms the spread 
of the gangrene may be too rapid to permit the vessels to be closed, 
and hence there may be formidable or fatal hsemorrhage. Metastatic 
abscesses may form in various organs, from infective emboli proceed- 
ing from the veins of the gangrenous parts. 

Symptoms. — Gangrene of the lung being usually a secondary dis- 
ease, the symptoms proper to the gangrene are obscured by the as- 
sociated malady ; and there are great variations at different periods. 
Before communication is established with a bronchus, when the diag- 
nosis is rendered certain by the character of the expectorated matters, 
the only symptoms are, a sudden depression of the powers of life, 
changes in the character of the existing fever, and a very high range 
of temperature. The symptoms become characteristic only when the 
sputa contain the materials of the gangrenous decomposition. The 
sputum is a sanguinolent, sanious, or sero-mucus fluid, of brownish dark- 
green, or even blackish tint, having a horribly fetid odor, compounded 
31 



450 



DISEASES OF THE RESPIRATORY ORGANS. 



of decomposing animal matter and fseces, and so sickening that tlie 
patient himself as well as those about him is nauseated by it. That 
the odor is due to foul gases is evident from the fact that the breath 
on forced expiration is full of the odor, and the sputa allowed to stand 
cease after a time to have the smell. The odor may precede the ex- 
pectoration, and may disappear for a time, to reappear again. The 
sputa on standing separate into three distinct layers : the uppermost, 
frothy, of a dark, greenish-yellow color, is composed of muco-pus 
chiefly; the middle layer is sero-albuminous and translucent; the lowest 
layer contains a sediment, greenish or brownish in color, with yellow 
or brownish flakes and masses of decomposing lung-tissue. Again, 
the sputa may be made up largely of black blood, in a decomposing 
state (Hertz). Chemically, the sputa have an alkaline reaction, and 
contain valerianic acid, the fat acids, I'eucin and tyrosin, triple phos- 
phate, and other products of decomposition. During the process of 
development of the gangrene, the symptoms indicate the existence of 
a grave disorder. Tlie elevation of temperature may be very consider- 
able, but the thermal line is that of septicaemia : irregular chills, high 
fever, and profuse sweats. The complexion is fawn-color, livid, the 
expression anxious, the face sunken, the skin relaxed, the pulse quick 
and feeble, and the respirations are hurried and catching. There is 
usually severe pain in the side, and the decubitus is toward and on the 
affected side. There is an incessant and very painful suppressed cough. 
Copious pulmonary haemorrhage may and usually does take place, 
started by the coughing. The fetid expectoration is apt to be swal- 
lowed, and excites by its presence nausea, vomiting, and diarrhoea, but 
the absorption of putrid matters and the congestion of the portal circu- 
lation will also cause watery and fetid stools. The operation of these 
causes rapidly exhausts the vital powers, and the patient lapses into a 
condition of profound adynamia. The physical signs are such as per- 
tain to changes in the density of the pulmonary tissue. On percussion, 
the sonority of the chest is lessened in proportion to the extent of the 
solidification, but, as there is more or less pulmonary tissue still pervious 
to air about the gangrenous portions, the dullness has somewhat the 
tympanitic quality. On auscultation, coarse rctles, mucous and sub- 
mucous, are audible, and there are bronchial breath and bronchial voice. 
After the softening and extrusion of the gangrenous portions, the 
physical signs will correspond, and the symptoms of a cavity will be 
present. 

Course, Duration, and Termination. — The course of the disease is so 
largely affected by the morbid condition on which it is ingrafted that 
no defined plan can be laid down. The circumscribed form is slower in 
development, and the symptoms are less formidable, than the diffused, 
and its duration is therefore longer. In those cases which tend to cure 
by the extrusion of the gangrenous mass through a bronchus, or by 



GANGRENE OF THE LUNG. 



451 



establishing a fistulous communication externally, the duration is pro- 
tracted, and not to be expressed with definiteness, because so much 
depends on the vital resources, and on the size of the gangrenous patch. 
The cases of partial recovery in which there is a cavity lined by a 
pyogenic membrane continue for months ; but every now and then 
fresh inflammation arises, more tissue is destroyed, until death finally 
ensues. The usual termination is in death, after two or three or even 
six weeks of the circumscribed form, and in a week or two of the dif- 
fused form. Certain accidents may occur which will materially abbre- 
viate either, as haemorrhage, perforation of the pleura, etc. The causes 
of death are various — pleuritis, peritonitis, haemorrhage, exhaustion, etc. 
Perforation of the pleura may cause death by the intermediation of 
pyopneumothorax, sudden distention of the cavity, severe dyspnoea, and 
collapse ; or it may cause a fistulous communication, emphysema of 
the connective tissue, and exhaustion, the fistula discharging ichorous 
serum and the foul-smelling products of gangrenous decomposition. 
Perforation of the diaphragm and purulent peritonitis may be a cause 
of death. The prognosis is, of course, exceedingly grave. 

Diagnosis. — It must be obvious that a diagnosis of gangrene of the 
lung is not possible when the mass affected does not communicate with 
a bronchus. Fetor of the breath is, of course, the first indication, but 
this is not pathognomonic by any means. As the pus in cavities and 
of dilated bronchi may by decomposition become fetid, and as bits of 
decomposing lung-tissue are cast off in the sputa, fetor of the sputa as 
a means of diagnosis must be accepted with limitations. The diag- 
nosis, under these circumstances, must rest largely with the clinical 
history, the severity of the symptoms, and the duration. Those familiar 
with the character of the odor in gangrene will recognize its penetrat- 
ing power and intensity, as compared with the much feebler odor in 
putrid bronchitis and in bronchiectasis. All of the symptoms in gan- 
grene of the lung are much more active and severe than are those of 
bronchitis. In gangrene, further, there are present the physical signs 
of pulmonary disease, which are absent in bronchitis. The differentia- 
tion of fetid sputa from a cavity in phthisis, from gangrene, is more 
difficult, but the greater intensity of the odor in the latter and the ap- 
pearance and composition of the sputa will serve to distinguish between 
them ; but, as cavities are present, the history and behavior of the two 
maladies must be taken into consideration. 

Treatment. — To maintain the powers of life by the free administra- 
tion of spirits, small doses of opium and quinia, and such aliment as 
beef -juice, egg-nog, etc., is the leading indication, to which all specific 
treatment must be subordinated. Excellent results have been obtained 
from turpentine (gtt. v) every two hours ; but still more from eucalyp- 
tol, which has been very much extolled recently. Eucalyptol is most 
easily taken in perls (ni v), but it can be made tolerable in an emui- 



452 



DISEASES OF THE RESPIRATORY ORGANS. 



sion. Benzoic acid, thymol, and carbolic acid, especially the last 
named, are very useful in correcting fetor, and also play the part of 
antiseptics, being eliminated largely by the lungs. Acetate of lead is 
the remedy most approved by Traube. Inhalations should be prac- 
ticed with those remedies, such as iodine, which may diffuse by vola- 
tilization, and with oxygen, which relieves the dyspnoea and improves 
the blood. Iodine, or the tincture, may be vaporized by a gentle 
warmth, and the fumes gradually introduced into the air the patient is 
breathing. Ethyl iodide, oil of eucalyptus, and turpentine, are among 
the most useful remedies to be administered by inhalation. 

CARCINOMA OF THE LUNG. 

Pathogeny. — Cancer of the lung is usually secondary, and very 
often succeeds to cancer of the breast removed by amputation. It 
may be primary, but rarely so. While cancer of the lung as a second- 
ary disease is more common in women, primary cancer of the lung is 
more common in men. It is a disease of advanced life, and is extreme- 
ly rare before forty ; nevertheless, a case has occurred at twenty-five. 
The form of cancer which attacks the lungs is usually the soft and 
rapidly growing variety known as encephaloid, and it occurs in two 
forms — in a distinct body or mass, and diffused through the tissue of 
the lung. In either case it presents the appearance of a yellowish- 
white, homogeneous, rather firm material, looking like brain-tissue 
which had been somewhat hardened — hence the name. When a mass 
is divided, a quantity of whitish, albuminous-looking fluid may be 
pressed out, and this fluid is called cancer-juice. Sometimes this can- 
cer-juice may be found in cyst-like nodules, or in delicate canals, whit- 
ish in appearance, accompanying the lymph-canals. Cancer may occur 
in any part of the lung ; when primary, in about two thirds of the 
cases in one lung, and when secondary in both, usually. The right 
lung is more frequently the seat of cancer, in so large a proportion as 
two to one. The distribution of cancer varies. In the primary form 
it occurs in nodules, from a pea to an orange in size, or there may be 
a great number of the smallest nodules, or a diffused infiltration involv- 
ing a part or the whole of a lobe, even of two lobes. When it forms 
a distinct tumor of considerable size, the neighboring parts may be 
compressed : the lung may atrophy from pressure ; the bronchi may 
be encroached on and closed, or the cancer elements may enter and fill 
them ; blood-vessels may be impinged on, their lumen obliterated, or 
they may ulcerate and haemorrhage result. The bronchi, trachea, and 
great vessels may be so far obstructed as to interfere with their func- 
tions respectively. The bronchial, tracheal, cervical, and axillary 
glands may be enlarged from simple adenitis, or from cancerous infil- 
tration. The pleura is usually invaded ; there may be an effusion into 



CARCINOMA OF THE LUNG. 



453 



the cavity, or adhesions unite the two surfaces, and the cancer elements 
may make their way to the surface as nodules, or in thin plates. A 
large cancerous mass may displace organs, push the heart aside, and 
force the liver and spleen downward. 

Symptoms. — When the cancer forms a tumor, the symptoms pro- 
duced by it are dullness over the place occupied, increase of the vo- 
cal fremitus, and bronchial voice and breath sounds over the dull area. 
These sounds may have the cavernous character if the cancer-mass 
surrounds, without compressing, a large bronchus. Also, a large artery, 
impinged on by the tumor, will give forth a distinct systolic hruit, 
which may be mistaken for aneurismal bruit, unless it is recognized 
that there is but one center of pulsation (the heart) in the chest. If 
the growth be so situated as to press on a large vein, there will be pres- 
ent oedema of the head and face, or of one side; if it press on the recur- 
rent laryngeal, spasm of the glottis, a peculiar cough (croupy), and dif- 
ficult breathing, or, if the pressure be long continued, paralj^sis with 
its usual consequences, will result ; if other nerve-trunks are impinged 
on, there will be deep-seated pains in the thorax, often of an excru- 
ciating kind, and there may be paroxysms simulating angina pectoris. 
The symptoms become more complex and difficult of interpretation, in 
cases of diffused or disseminated cancer. There are present the signs 
of consolidated lung-tissue on one or both sides. There are no adven- 
titious sounds, but the respiration has a rather blowing character in 
some situations; in others, that of bronchial voice and bronchial breath. 
The diagnosis rests on these facts : all acute diseases are excluded, as 
this is comparatively slow in development and is free from fever ; it 
can not be chronic pneumonia, as there is no localization of the deposits; 
from tuberculosis it is separated by the absence of fine crackling, and 
by the fever-movement ; and, lastly, some indurated glands may be 
found in the neck or axilla, and possibly the traces of a former opera- 
tion. There will be some difficulty of breathing if the deposits are 
extensive, and a dry, hard cough ; but there may occur, finally, rusty- 
colored, semi-transparent, gelatinous expectoration. The difficulty of 
breathing depends on different conditions from those which obtain in 
the other form. In this case, the degree in w^hich the air-space is en- 
croached upon determines the amount of dyspnoea ; in the other, com- 
pression of bronchi, or trachea, or displacement of the lung, affects the 
breathing. The character of the cough is very different, according as 
it is due to deposits in the lungs, to pressure on a bronchus, to irrita- 
tion of the recurrent laryngeal, or pneumogastric nerves, etc. Besides 
the symptoms produced by and due to the presence of the cancer in 
the lungs, there is soon developed the cancerous cachexia, which is 
manifested by the following symptoms : progressive emaciation, weak- 
ness and sense of fatigue, a weak, small pulse, a peculiar earthy or 
fawn-color tint of the skin, pearly sclerotic, anorexia, oedema of the 



454 



DISEASES OF THE KESPIRATORY ORGANS. 



ankles, etc. The rate of decline due to the cancer deposits is acceler- 
ated by the harassing cough, the dyspnoea, the dysphagia, and the 
pain. As the cancer extends, all of the rational symptoms increase in 
severity, and the physical signs more clearly indicate the diffusion of 
the cancer elements through the lungs, or the enlargement of the tumor. 

Treatment.— This must be directed by the symptomatic indications. 
Anodynes to relieve pain and support for the increasing weakness are 
the measures necessary. 

HYDATIDS OF THE LUNGS— ECHINOCOOOI. 

Definition. — Hydatids found in the lungs are the intermediate or 
larval condition of the toenia echinococcus — the tape-worm of the 
dog — and are therefore designated echinococci. The cysticercus cellu- 
losus, the larval state of the toenia solium, is very rarely, if ever, found 
in the lungs. Echinococci migrate from the intestines and take up 
their abode in the lungs. Each cyst contains the embryo — the scolex 
with its four suckers, and row of booklets, inverted and contained 
within its cyst. 

Dermoid cysts are rarely found in the thorax, but they should not 
be confounded with echinococci. 

Pathological Anatomy. — Hydatid cysts usually exist in the paren- 
chyma of the lungs, but sometimes develop in the cavity of the pleura, 
or they may be present in both at the same time. They are found in 
the inferior lobe, and chiefly on the right side. Often, the intra-tho- 
racic cyst is a solitary hydatid, which fills the cavity, distending and 
enlarging the chest on that side, pushing out and widening the inter- 
costal spaces, compressing the lung against the root and the spinal col- 
umn, and forcing the heart downward or to one side, and depressing 
the liver or spleen. If the cyst is large, the pleural surfaces may be 
united and the cavity obliterated. Adhesions are often formed to 
a bronchus, which may be perforated and a cure effected by discharg- 
ing the parasite by expectoration. The cavity which remains con- 
tracts and cicatrizes. In other cases the parasite is not discharged, 
but sets up an inflammatory induration about it, which excites fever, 
cough, and expectoration, that ultimately exhaust the patient unless 
carried off by some intercurrent affection. Rarely do hydatids come 
into relation with the vessels of the thorax, but a vessel may be in- 
vaded, with results determined by its size. Habershon * repoi'ts a case 
of a youth of seventeen in whom repeated hoemorrhages occurred, from 
an opening into a branch of the pulmonary vein, produced by " ulcera- 
tion at the seat of the hydatid cyst." In this case tubercular disease 
followed the troubles due to the hydatids. Sometimes the cysts attain 



* " Guy's Hospital Reports," third series, vol. xviii, 1872-"73, p. 3*73. 



HYDATIDS OF THE LUNGS. 



455 



sufficient volume to cause death by suffocation. In other cases death 
is produced by atrophy of the inferior lobes of the lungs. In a larger 
number of cases, pneumonia and gangrene of the lung, induced by the 
presence and pressure of the hydatids, are the cause of death. The 
length of time hydatids continue in the lungs is measured by years. 
The ordinary duration is two to four years. 

Symptoms.^ — The cysts must attain a sufficient size to interfere with 
function before symptoms are produced. More frequently than in 
other situations, hydatids of the lungs give rise to pains which may be 
felt in the back, in the side, or in the epigastrium. The pain is severe, 
persistent, and is somewhat paroxysmal, and its situation may indicate 
the seat of the mischief. The decubitus is on the back or on the af- 
fected side. The most marked as well as the most constant symptom 
is dyspnoea, which is alv/ays present in a moderate degree unless the 
cyst is very voluminous, and there occur also violent paroxysms, in 
which the breathing is suffocative. The cough is dry, or accom- 
panied with a little expectoration, unless the cyst communicate with a 
bronchus, when the cough is incessant and the expectoration enormous, 
consisting of a serous liquid or earthy and calcareous masses, filled 
with the debris of hydatids. Sometimes the expectoration is fetid, from 
gangrene, or bloody. Small hydatids of the volume of a pigeon's-egg 
may be expected, but usually fragments and booklets. The expectora- 
tion takes place at intervals sometimes of weeks or months ; then a 
great mass may come up, almost suffocating the patient. 

The physical signs will depend largely on the volume attained by 
the cysts, their number and situation. There may be seen, on inspec- 
tion, an enlargement of the affected side, dilatation of the intercostal 
spaces, and displacement of the heart or of the liver, or of both. Fluc- 
tuation or the purring tremor will be felt only if the cysts are protruding 
through the chest-walls, and if a number of daughter-vesicles are con- 
tained within the parent-cyst. On percussion, there will be dullness 
according to the space occupied, and increase of resistance, commencing 
below the clavicle, over the inferior lobe. The vocal fremitus is 
diminished. The vesicular murmur is absent, replaced by bronchial 
voice and bronchial breath. Egophony may be audible. The signs 
of a cavity will be present when the cysts are expectorated. 

Course, Duration, and Termination. — The origin and early develop- 
ment of echinococci of the lung necessarily escape detection. It is only 
when they are large enough to interfere with neighboring parts that 
symptoms are produced. The whole course is usually completed within 
four years, sometimes earlier, if the opportunity for free discharge ex- 
ists by an opening into a bronchus. In forty cases of which Davaine * 
has given an account, there were fifteen recoveries and twenty-five 

* '* Traite des Entozoaires," op. cif., whose account I have closely followed in this 
subject. 



456 



DISEASES OF THE RESPIRATORY ORGANS. 



deaths, the termination by expectoration of the hydatids occurring in 
twelve cases. Of the twenty-five fatal cases, twelve or thirteen occu- 
pied the inferior lobe, and five or six the upper lobe. In another col- 
lection of cases quoted by Davaine, of sixty-two terminating in recov- 
ery forty-five recovered by the expectoration of the cysts, and seven 
by puncture of the chest, expectoration also occurring. The propor- 
tion of cures to cases in the last-mentioned collection was sixty-two to 
eighty-two. The termination by death is therefore more common than 
recovery. Death is due to a variety of causes — to exhaustion from 
profuse purulent expectoration, hectic and marasmus, to tuberculosis, 
to h£emorrhage, to gangrene, to pleuritis, etc. 

Diagnosis. — There are no well-marked distinctions between hydatid 
cysts and pleuritic effusion, as regards the physical signs, but they dif- 
fer widely in history. Pleuritis begins by a violent pain in the side, 
chill and fever, the effusion following in a short time. Echinococci 
very slowly develop, and the symptoms of effusion are not produced 
until after many months. Puncture and examination of the fluid for 
the characteristic booklets may be required, to determine the question 
at issue. When expectoration of echinococci or of fragments takes 
place, there can be no doubt left. 

Treatment. — When the existence of hydatid cysts is ascertained, 
there should, if possible, be made a free opening to permit their evacu- 
ation. Puncture and withdrawal of fluid will arrest their growth, 
but, as decomposition, suppuration, even gangrene may result, the ex- 
trusion of the cysts should be procured, if possible. Free opening into 
the cyst cavity, and drainage with antiseptic precautions, has proved 
very effective in the hands of Dr. Fenger, of Chicago. Such a cavity, 
when free exit is secured, can be washed out with solutions of germi- 
cides of suitable strength. 

CATARRH OF THE BRONCHIAL TUBES— ACUTE BRONCHITIS- 
CAPILLARY BRONCHITIS. 

Definition. — The term hrofichitis is limited to a catarrhal inflamma- 
tion involving the bronchial tubes, of a caliber above the terminal tubes. 
Catarrhal inflammation of these terminal tubes, or bronchioles, is desig- 
nated capillary bronchitis, and if associated with atelectasis and catar- 
rhal inflammation of the alveoli, is then known as catarrhal pneumonia 
or broncho-pneumonia. If the trachea is at the same time affected with 
the bronchial tubes, the disease is named tracheo-hronchitis. If the 
inflammation is general over the whole tube, it is called diffuse bron- 
chitis ; if limited to a part, circumscribed bronchitis. According to the 
rate of progress, it is acute or chronic, but the difference is slight. 

Causes. — Bronchitis is very dependent on climatic conditions. A 
humid, changeable, and cold climate favors it, while dryness, uniform- 
ity, and warmth of climate have the opposite effect. More than any 



ACUTE BRONCHITIS. 



45T 



other single factor does humidity inflaence and promote the occurrence 
of bronchitis. Those seasons of the year characterized by the most 
rapid alternations of temperature, by cold and damp winds, and by ex- 
cess of humidity, are especially liable to produce bronchitis. All 
depressing hygienic influences, unsuitable clothing, exposure to damp, 
cold air — especially when the body is warm and perspiring — are influ- 
ential factors. In a lowered state of the general health from any cause, 
the bronchial mucous membrane is more susceptible to evil influences. 
Bronchitis occurs in greater ratio in men, because they are more ex- 
posed to the conditions producing it. Age has an unquestionable in- 
fluence. The extremes of life are more susceptible, but in infancy 
bronchitis is more frequent than in old age, but from different causes. 
The inhalation of irritating gases and vapors and the dust of various 
occupations will excite inflammation and catarrh. Among the causes 
must be placed minute organisms, the pollen of plants, which excite 
local irritation of the respiratory tract, and epidemics of catarrhal dis- 
eases. Valvular affections of the heart, w^hich maintain congestion of 
the lungs and bronchi, necessarily induce a catarrhal state of the bron- 
chial mucous membrane. 

Pathological Anatomy. — The initial factor in inflammation of the 
bronchial mucous membrane is hypersemia, or increased blood-supply, 
the whole surface marked by a fine arborescent or punctiform redness, 
or spots or limited areas only are thus affected. The depth of color 
depends on the period and intensity of the disease — recent and severe 
inflammation causing deep redness, and passive inflammation a dark- 
red, even purplish injection. It is hardly ever the case that the entire 
bronchial tract is invaded by the redness, but portions of the trachea, 
a considerable part of the primary and some portions of the second and 
third divisions of the bronchi. In old cases the redness disappears and 
is replaced by a grayish, ashy hue, with relatively numerous enlarged 
and tortuous vessels showing through. Nutritive changes in the epi- 
thelium, overgrowth of the glands, and proliferation of the connective- 
tissue cells of the submucosa, increase the thickness of the mucous 
membrane. The cartilaginous rings also undergo important changes, 
and the peribronchial connective tissue is the seat of an active hyper- 
plasia. The new connective-tissue elements displace the cartilage. 
The secretion of the mucous membrane is changed in character ; at 
first the sudden hypersemia suspends the production of mucus and the 
membrane is dry ; the next step consists in an increased production 
of mucus, soon followed by purulent elements, which rapidly prepon- 
derate, giving the expectoration a yellowish color. The amount of 
secretion varies in different cases : when it is deficient, the case is 
known as dry catarrh ; when pus is copiously discharged, it receives 
the name of hr anchor rlioea. The extension of bronchitis to the alveoli 
of the lungs and the collapse of lobules constitute catarrhal pneumo- 
nia. Emphysema may also result, especially the vicarious emphysema. 



458 



DISEASES OF THE RESPIRATORY ORGANS. 



and when tlie atelectatic condition happens to many lobules. The 
bronchial glands frequently participate in the inflammation, become 
hypersemic, swollen, and filled with secretion, or the gland elements 
undergo hyperplasia and ultimately the cheesy transformation. 

Symptoms. — There may be catarrh of the upper air-passages, and 
at the same time there is experienced a raw and sore sensation under 
the sternum, and a dry, harsh, and rather ringing cough, which awak- 
ens pain, and has often a suppressed character because of the pain. 
At first the cough is dry, corresponding to the dry stage of the mucous 
inflammation, and is most troublesome in the evening. There are also 
much muscular soreness and a sense of fatigue, but no other symptoms 
of illness. In other cases there may be some feverishness, headache, 
and anorexia. The cough, which was dry, now brings u]) some mu- 
cus, at first only after repeated coughing, but in a short time easily 
and abundantly, and the expectoration at last has an entirely purulent 
character, and comes up in globular masses. The fever now disap- 
pears, the pain and soreness cease, the cough is easy and less frequent, 
the appetite is restored, and the return to health is completed in a few 
days. Such is the course of a simple acute bronchitis (a cold on the 
chest), which terminates in recovery in about sixteen days. In such a 
case the changes in the mucous membrane, we may suppose, consist in 
hypera3mia and swelling, with increased secretion of the glands and 
more or less destruction of the epithelium. The more severe cases of 
bronchitis come on with muscular soreness, headache, chilliness, and 
fever. There is not a sing^le violent chill markino^ the onset of the 
disease, but a succession of chills in which there is merely some chil- 
liness felt several times during the course of the day, and having no 
influence on the fever, which has an exacerbation in the evening and a 
remission in the morning, or a complete intermission. Sometimes the 
febrile movement exists without there being any other symptoms for 
several days, but the more usual onset is the simultaneous appearance 
of chest symptoms. There is a sensation of heat and stuffing under the 
sternum ; cough, which is accompanied by soreness within the chest, 
now comes on, and it is dry, harsh, ringing. The frequency and force 
of the coughing make the diaphragm and chest-muscles sore, and now 
and then the stomach is emptied in a violent paroxysm. In a few days 
— usually from three to five — the dryness of the mucous membrane 
ceases, and abundant secretion of mucus now takes place, and there is 
brought up frothy mucus, which day by day assumes more of a puru- 
lent character. The fever now declines somewhat, but frequently a 
gastro-intestinal catarrh is lighted up and diarrhoea supervenes. This 
is apt to be the case with children, in whom the nausea, vomiting, and 
diarrhoea assume an important position. The coincident development 
of bronchial and gastro-intestinal catarrh produces a complexus of 
symptoms to which the term catarrhal fever has been applied. In 
bronchitis the sonority of the chest is not altered from the normal. 



ACUTE BROXCniTIS. 



459 



During the dry stage the swelling of the mucous membrane narrows 
somewhat the lumen of the bronchial tubes, but there is no secretion 
to produce a new sound. The passage of air through narrowed tubes 
modifies the vibrations, and hence the terms sibilant and sonorous 
rciles, audible at this stage, both with inspiration and expiration. 
When secretion of mucus, muco-pus, and pus succeeds to the dryness, 
the rales are said to be moist. Those are siih-crepitant which are produced 
in the smaller tubes, and mucous and suh-mucous formed in the larger 
tubes. The largest sounds, or gurgling, are produced only in cavities, 
or that which is equivalent, dilated bronchi. The sub-crepitant is more 
distinct in inspiration, but all of these relies are audible both in inspi- 
ration and expiration. Moist sounds are modified by coughing and 
expectoration — may, indeed, be caused to disappear by them. 

The usual termination of these cases of bronchitis is in resolution. 
The fever ceases, the tongue cleans, the appetite improves, the cough sub- 
sides, the expectoration is copious, easy, and purulent, but the amount 
declines rapidly. Certain types of subjects manifest a great suscep- 
tibility to attacks of bronchial catarrh, and the effects do not cease. 
This is the case in the dyscrasice, and when the catarrh is due to car- 
diac disease there can only be a temporary subsidence in the severity 
of the symptoms. In those debilitated by constitutional causes, or in 
subjects of the strumous type, the acute attack passes into the chronio 
form. Acute bronchitis, by an extension of the inflammation to the 
finest tubes, becomes capillary hroncldtis. This is often the case in 
whooping-cough, and in the eruptive fevers — notably in measles. In 
those debilitated by previous illness, in the old, and in infants, capil- 
lary bronchitis is a most serious malady. A sudden increase in the 
temperature and a marked difficulty of breathing announce the onset 
of this disease when it arises as just indicated. So difficult is the 
breathing that the patient calls into use the auxiliary muscles of respi- 
ration ; unable to lie down, he sits, inclined forward, the arms resting 
on some support, struggling to get breath, and the respirations, shallow 
and incomplete, reaching in an adult to forty, in infants to eighty per 
minute. The difficulty of breathing is incessant ; although, now and 
then dislodging some mucus by coughing or vomiting, there is a tem- 
porary alleviation of the distress. At first the respirations, although 
hurried and oppressed, are normal ; but, when the air can not enter, the 
lungs are not expanded, and the diaphragm is not dej^ressed, the inferior 
part of the chest and the epigastrium are drawn in with each inspira- 
tion instead of being elevated, while the upper portion of the chest re- 
mains immovable. At first the face is red, the eye bright, and the 
skin hot with the unwonted effort, but as the air fails to reach the 
lungs the blood is not oxygenated, the face becomes pale, the veins 
enlarged, and the countenance has an increasing duskiness from the 
accumulation of carbonic acid in the blood. The restlessness and 
anxiety yield to an increasing stupor, and the approaching cardiac 



460 



DISEASES OF THE RESPIRATORY ORGANS. 



failure is announced by rapidity and feebleness of the pulse. When 
no elforts succeed in removing the obstruction to the entrance of air, 
death takes place in four or five days, but the duration is longer if by 
vomiting or other means the access of air is secured, even for a brief 
period, to the alveoli of the lungs. When a favorable termination is 
about to take place, the dyspnoea becomes less urgent, the pulse im- 
proves in volume and lessens in rate, the fever diminishes, the expec- 
toration is less viscid and comes up more abundantly, and ten or twelve 
days from the onset convalescence is fairly inaugurated. More or less 
simple bronchitis may persist for weeks longer. The physical signs are 
similar to those of bronchitis, except the differences due to the volume 
of the tubes attacked. Besides the coarser sounds of bronchitis, the 
dominating rale is the sub-crepitant, audible all over the chest. As in 
capillary bronchitis collapse of lobules takes place, the physical signs 
of atelectasis are superadded. These have already been sufficiently 
discussed. 

Course, Duration, and Termination. — Simple bronchitis usually ter- 
minates in resolution in about ten to fifteen days. In children the 
course may be more protracted, and the symptoms more severe, if 
complicated by gastro-intestinal troubles. The termination may be in 
the chronic form of the disease. There may be an extension of the 
morbid action from the larger to the finest bronchial tubes. Capillary 
bronchitis pursues a more rapid course, and may terminate in four or 
five days, but it usually continues up to the ninth, even twelfth day. 
The mortality from capillary bronchitis is large, because of the occur- 
rence of atelectasis and broncho-pneumonia or catarrhal pneumonia. 

Diagnosis. — Acute bronchitis is to be differentiated from catarrhal 
pneumonia and croupous pneumonia. Bronchitis pursues a much milder 
course, is of shorter duration, and is greatly less dangerous to life. 
While the moist sounds are the same in the two diseases, the sub-crepi- 
tant rale preponderates in catarrhal pneumonia, and in the latter the 
vesicular murmur is replaced by blowing or bronchial breathing and 
bronchial voice. Bronchitis commences by chilliness persisting for 
several days — pneumonia by a distinct and severe rigor ; in bronchitis 
there is fever of moderate height — in pneumonia, the range of temper- 
ature is very high ; in bronchitis, the fever declines gradually — in 
pneumonia, there is a sudden defervescence ; in bronchitis, the sputa 
consist of muco-pus and pus — in pneumonia, of a peculiar viscid mate- 
rial stained with blood ; in bronchitis, there are moist sounds, with sub- 
crepitant rale — in pneumonia, there is crepitant rale ; in bronchitis, 
there are no sounds indicating pulmonary lesions — in pneumonia, there 
are bronchial breathing, bronchial voice, etc. Bronchitis of the larger 
is to be distinguished from bronchitis of the smaller tubes, by the 
dyspnoea, by the fineness of the sounds, and the greater danger to life. 
The onset of catarrhal pneumonia from bronchitis is announced by 



CHRONIC BRONCHITIS. 



461 



the increased difficulty of breathing, the rise of temperature, and the 
diminishing sonority of the chest over the affected parts, with the aus- 
cultatory phenomena of consolidation. 

Treatment. — The simplest means suffice for an uncomplicated case 
of acute bronchial catarrh. The combination of tartar emetic (gr. yig-) 
and morphine (gr. in some sirup of lactucarium, or in water, a 
mustard-plaster to the chest, and confinement to bed, will afford satis- 
factory relief. In children, sirup of ipecac, sirup of tolu, and paregoric 
usually suffice. If there is much fever, and the pulse active, tincture 
of aconite-root (gt. j) should be added to the ipecac and paregoric. 
When the acute symptoms have subsided, the stimulant expectorants 
should be used — acetum scillse, sirup of senega, and sirup of tolu, for 
example. When the bronchitis is severe, there is high fever, and the 
inflammation seems disposed to invade the finer tubes, and especially 
if the finer tubes are invaded, tartar emetic in sufficient quantity to 
produce a little nausea, morphine in very small doses, and the tincture 
of aconite, are highly serviceable. The more the finer tubes are in- 
vaded, the greater the need of ammonia, carbonate or chloride, and the 
iodide. Should there be much obstruction, emetics of subsulphate of 
mercury or of apomorphine must be employed to tide over the emer- 
gency, and then the iodide and carbonate of ammonia, in small doses, 
should be given frequently. Should the temperature rise high and 
continue so, antipyretics, as cold baths and quinine, more especially the 
latter, must be administered. A temperature requiring antipyretics 
may be attained when a simple bronchitis becomes a capillary bron- 
chitis or broncho-pneumonia. A persistently high temperature greatly 
increases the danger of cardiac failure. If there be indications of such 
failure, ammonia carbonate and alcoholic stimulants must be freely 
but judiciously administered. The diminution in the supply of oxygen 
and the accumulation of carbonic acid are important sources of danger 
in capillary bronchitis. The timely use of emetics, by giving at least 
temporary admission of air, will postpone the period of stupor from 
carbonic-acid narcosis. When bronchitis in children assumes the aspect 
of catarrhal fever, the remedies employed must be different in charac- 
ter. Nauseants, emetics, and irritants must be discontinued if they 
have been used. Paregoric, with some carbonate of ammonia, in sirup 
of tolu, is a good prescription in these cases. In all cases of the differ- 
ent forms of acute catarrh of the bronchial tubes, alimentation is 
important, but especially so in those cases accompanied by gastro- 
intestinal disorder. 

CHRONIC BRONCHITIS— CHRONIC BRONCHIAL CATARRH. 

Definition. — By this term is meant an inflammation beginning in 
the mucous membrane of the bronchial tubes, chronic in type, and in- 



462 



DISEASES OF THE RESPIRATORY ORGANS. 



volving not only the mucous membrane, but the substance of the tubes 
and the peribronchial connective tissue. 

Causes. — Chronic bronchitis but rarely succeeds to a pronounced 
acute attack. Usually the early symptoms escape recognition, or the 
chronic form is a resultant of not one but numerous acute attacks. 
This malady is always associated with obstructive lesions of the heart 
or lungs. It accompanies or is a local development of the dyscrasige, 
as rickets, scrofula, Bright's disease, and of the infectious diseases. 
The tendency to it may be inherited, or rather a type of mucous mem- 
brane disposed to such changes may be transmitted. 

Pathological Anatomy. — The mucous membrane is brownish in color, 
or has a steel-gray color. In other examples, owing to the develop- 
ment of vascular loops, it has a bright-red color. The follicles of the 
mucous membrane are swollen and enlarged by hypertrophic thicken- 
ing of the connective tissue, and by accumulation of their contents. 
The connective tissue, especially of the posterior part of the tubes, 
and the peribronchial connective tissue, become greatly thickened ; the 
cartilages are invaded and much weakened. Under the strain of cough- 
ing, especially if there be at the same time firm pleuritic adhesions, the 
bronchi yield and dilate. The dilatations are cylindrical, fusiform, 
and sacculated. In cylindrical dilatations the tube or tubes are uni- 
formly enlarged throughout ; in the fusiform variety the enlargement 
has a spindle-shape, and in the sacculated there is a lateral protrusion 
forming a sac or a cavity. To these might also be added the monili- 
form, in which there is an enlargement of one part, then the tube is 
normal, then again an enlargement, so that the normal portions by com- 
parison with the dilated seem to be contracted. 

The secretions in chronic bronchitis differ greatly from the normal. 
Fragments of the detached epithelium, mucus, and pus-corpuscles, are 
the morphotic elements, the purulent being very largely in excess. 
Usually the secretion is very abundant, greenish-yellow in color, and 
sometimes fetid. When the secretion consists of young cells and mu- 
cus corpuscles and granules, it is called mucous catarrh ; when the cel- 
lular elements are not present, and the secretion is viscid, colorless, 
without odor, and resembling w^hite of egg, it is called pituitous catarrh 
or hronchorrhma / if the secretion is scanty, tough, rather glistening, 
semi-transparent, and occurs in defined, globular masses, it is entitled 
dry catarrh. Whenever the secretion is retained and undergoes decom- 
position, as is apt to be the case when the tubes are dilated, especially 
in the saccular form, it is known as fetid bronchitis, the fetor being 
chiefly due to the fat acids. 

Symptoms. — If there be no complications, chronic bronchitis is not 
attended by fever. When it occurs with disease of the heart, Bright's 
disease, or other dyscrasise, the clinical features are those of the origi- 
nal malady, bronchitis being one only of the morbid complexus. As a 



CHRONIC BRONCHITIS. 



463 



substantive affection succeeding to acute attacks, it is slow of develop- 
ment. There are observed, for some years, autumnal and winter seiz- 
ures of bronchitis, which cease with the warmer and more stable 
weather of the summer. It may be a number of years before the 
bronchitis becomes constant, which indicates the existence of perma- 
nent changes in the tubes. In the so-called dry catarrh there is but 
little expectoration, and that is brought up with difficulty, and after 
repeated and most distressing paroxysms of coughing. Next to cough- 
ing the most important symptom is dyspnoea, due to the viscidity of 
the exudation, to the swelling of the mucous membrane, and the impli- 
cation of the finer tubes. The difficulty of breathing is not consider- 
able when at rest, but exertion at once develops it, and it is accom- 
panied by more or less wheezing. Owing to the impaired elasticity of 
the lung and the dilatation of the tubes, the upper part of the thorax 
is kept in the position of maximum inspiration, and the expiration is 
prolonged and difficult. The result is, that the supply of oxygen is 
insufficient for the depuration of the blood, and cyanosis appears, the 
face becomes congested, the lips and mucous membrane bluish, and the 
superficial veins enlarged. The pulmonary circulation is hindered by 
reason of these conditions, venous stasis ensues, and oedema slowly 
develops about the ankles. The habitual difficulty of breathing is now 
and then varied by attacks which have an asthmatic character, excited 
by the inhalation of dust, remaining in a crowded apartment, taking 
cold, and especially by an attack of acute bronchitis with profuse 
secretion (humid asthma). These seizures are not very protracted, and 
terminate after some hours by an abundant discharge of mucus. The 
cases of chronic bronchitis characterized by profuse expectoration dif- 
fer from the preceding type in several respects — in a more abundant 
expectoration, in a less troublesome cough, and in less habitual difficulty 
of breathing. In these cases of so-called humid bronchitis there are 
occasional paroxysms of dyspnoea, due to extension of the morbid 
process to the smaller tubes, causing difiiculty of breathing by swell- 
ing of the mucous membrane, by accumulation of secretion, etc. 
With or without such paroxysms, the chief troubles arise from the 
cough, which is most annoying at night or in the early morning, and 
an abundant expectoration. The sputa consist of muco-pus, or of a 
semi-transparent, albuminous, viscid fluid (bronchorrhoea), or of a green- 
ish-yellow pus, and the variations represent differences in the local 
changes already designated. Percussion reveals no change in the nor- 
mal sonority of the lungs in uncomplicated cases. If emphysema, or 
broncho-pneumonia, or fibroid phthisis have occurred, there will be 
changes in sonority, but these diseases are not in question. In dry 
bronchitis, on auscultation sibilant and sonorous rales of every variety 
will be heard ; in humid bronchitis, mucous and sub-mucous, and sub- 
crepitant rales will be abundant according to the amount of secretion 



464 



DISEASES OF. THE RESPIRATORY ORGANS. 



present in tlie tubes. The vesicular murmur may be entirely displaced 
by the loud rales, especially the more nearly the lesions approach to 
the acini. Dilatation of the tubes impresses some special characters 
on the rational and physical signs. The expectoration is very abun- 
dant and often has a butyric and fetid odor, and is sometimes, as in the 
morning, expectorated in a great mass, due to the emptying of a sac- 
culated dilatation of a bronchus. This expectoration, when collected, 
differs from that of phthisis in being homogeneous and of a greenish- 
yellow color. Haemorrhage from a dilated bronchus is a very mislead- 
ing symptom ; it may occur gradually and continue for some time, there 
being considerable loss in the aggregate. The blood coming from a 
dilatation is fluid, dark, and does not clot, and it may be mixed with 
the contents of the sac. The physical signs of dilated bronchi are 
practically the same as those of a cavity formed in other ways, but 
the distinction may be made by the history of the case and by the 
situation of the dilatation. 

Course, Duration, and Termination. — Chronic bronchitis pursues an 
essentially chronic course, but it is diversified by variations in the 
intensity of the symptoms, by remissions and intermissions. These 
intermissions are only possible in the early period ; after a time the 
symptoms persist. Chronic bronchitis may continue during a lifetime, 
and death be caused by some other disease. Recovery may ensue in 
the milder cases, and is more likely to occur in young than in old sub- 
jects. Severe cases of bronchitis lead to the production of other mal- 
adies. The long-existing purulent exudation in the tubes, interstitial 
pneumonia having been produced by the extension of the peribron- 
chial connective-tissue inflammation, excites tubercular deposition. 
Fibroid phthisis is usually, probably always, produced in this way, 
chronic bronchitis initiating the series of morbid changes. Emphy- 
sema is a result of dry catarrh, for in this case the chronic inflamma- 
tion is seated in the finer bronchi, the secretion is highly viscid, the 
membrane much swollen — conditions most favorable to collapse of 
lobules and emphysema. Hypertrophy and dilatation of the right 
cavity, venous stasis, and general oedema are also results of chronic 
bronchitis, and in this way a considerable proportion terminate. The 
disturbed circulation in the lungs and the venous stasis cause conges- 
tion of the liver and of the kidneys, and death may be due to the 
maladies thus created. 

Diagnosis. — The same considerations govern the diagnosis of chron- 
ic as of acute bronchitis. The disease with which chronic bronchi- 
tis is most apt to be confounded is phthisis. The difficulty of sepa- 
rating chronic bronchitis with sacciform dilatation from phthisis 
with cavities is very great. The differentiation must rest on the 
history of the cases, the evidence of pulmonary lesions outside of 
the cavity, to be discovered in phthisis and not in bronchitis, and 



CHRONIC BRONCHITIS. 



465 



in examination of the sputa, those of phthisis containing elastic fibrous 
tissue, etc. 

Treatment. — The indications of treatment vary somewhat with the 
form. In dry bronchitis, full doses of iodide of potassium, or prefer- 
ably iodide of ammonium (ten to twenty grains), every three hours 
when the difficulty of breathing is great, are very effective. For the 
interval between the asthmatic paroxysms, the best results are obtained 
by a combination of iodide of ammonia and arsenic, with a balsamic 
expectorant, as eucalyptol, turpentine, copaiba, cubebs, etc. The per- 
sistent use of these remedies will often accomplish important results, 
and will in all cases afford relief, if not cure. When there is profuse 
expectoration, quinine with atropine, and codeine, to quiet cough, and 
the balsams, are the most efficient remedies. If the expectoration is fetid, 
the free internal use of quinine, eucalyptol, and turpentine, is to be com- 
mended, and inhalations of the vapor of turpentine and of iodine, or 
atomization of benzoate of sodium, carbolic or salicylic acid, or thymol, 
may be practiced. Of these remedies applied by atomization, carbolic 
acid is most efficient. In all cases of chronic bronchitis with consider- 
able expectoration, much good results from the persistent use of the 
now well-known phosphate of iron, quinine, and strychnine. The lacto- 
phosphate of lime is also highly useful, probably because of the waste 
of this important material under these circumstances of profuse sup- 
puration. Arsenic is highly useful when the secretion is not abundant, 
as in dry bronchitis. It may be combined with the iodides, or with 
the sirup of the lactophosphate of lime. The hypophosphites, as well 
as the compound phosphates, are useful when there is waste by sup- 
puration. Alcohol has the power to diminish suppuration and to arrest 
fermentative processes, and is therefore useful in chronic bronchitis. 
Whisky is the best alcoholic in such cases. It may betaken with cod- 
liver oil, the two forming a nutrient of much value — a teaspoonful of 
cod-liver oil and a tablespoonful of whisky after meals. A generous 
supply of nutritious aliment is, of course, highly necessary. 

As taking cold is the principal cause of attacks of catarrh (employ- 
ing that term to indicate the nature of the influences causing catarrh), 
it is highly important to avoid this accident by suitable clothing, by 
good air, and by favorable hygienic surroundings. If a cold should 
occur, the patient ought to receive at once an efficient dose of quinine 
and morphine (gr. xv — gr. ss.). As a humid, variable climate, character- 
ized by cold winds and extremes of temperature, is very unfavor- 
able, a change to a mild, equable, and dry climate should be advised. 

PSEUDO-MEMBRANOUS OR CROUPOUS BRONCHITIS. 

Definition. — Croupous hronchiUs is an inflammation of the bron- 
chial mucous membrane, characterized by the exudation of a false 
32 



466 



DISEASES OF THE RESPIRATORY ORGANS. 



membrane. It corresponds to croupous enteritis and to laryngeal 
croup. It may be acute or chronic. 

Causes. — The ordinary causes of bronchitis excite this form appar- 
ently, but nothing is known of the conditions which give this direc- 
tion to the products of inflammation. The cases occur usually in 
youthful subjects, from six to forty * years of age, and in those who 
have been subject to attacks of bronchial catarrh. A depressed state 
of the body, and possibly an inherited tendency, are also causes. Ac- 
cording to Riegel, pulmonary haemorrhage sometimes precedes, accord- 
ing to Street succeeds to attacks of croupous bronchitis. 

Morbid Anatomy. — There are two forms of the croupous process in 
the bronchial tubes — the diffused and the circumscrihed : the former 
are so designated because the exudation extends from the trachea 
through all the divisions of the bronchi ; the latter, because confined 
to certain tubes. The mucous membrane has been found both intensely 
injected and pale ; the epithelium intact, or entirely removed over the 
whole extent of the surface covered by the exudation. Sometimes cili- 
ated and cylindrical epithelium has been found embraced in the casts ; 
in other cases none has been found. These contradictory observa- 
tions are due to the fact that the examinations were made at differ- 
ent stages of the disease. Indeed, displacement of the epithelium is 
not a necessary part of the process of membrane formation. It is 
most probable that an albuminous solution is poured out, and white 
corpuscles migrate, the whole consolidating. It may happen that some 
epithelial cells are embraced, but this is not necessary. The tubular 
casts form an outline of the tubes in which they were produced. They 
may be rolled up into a ball, or expelled in fragments, or as a whole. 
The author has had a case in which a complete cast of one bronchus 
and all of its subdivisions was expelled entire. The casts differ much 
in thickness and length. Those coming from the upper tubes are 
shorter and straighter, and terminate in fine prolongations ; those from 
the lower tubes are longer, and gradually divide into smaller casts. 
They are not solid usually, at least the larger casts are not, and contain 
in their interior mucus and air. They have a lamellated structure, 
and the lamellae have a concentric arrangement (Riegel) f. The casts 
are elastic and compact, and bear a good deal of strain. They are 
whitish or yellowish-white in color, and consist of a "hyaline base- 
ment substance," \ sometimes fibrillated, as was the case in the author's 
observation. 

Symptoms. — There are two forms — as regards the clinical features 
— the acute and chronic. The acute attacks begin as an ordinary acute 

* Dr. Street's case — a man aged thirty-nine, " American Journal of Medical Sciences," 
January, 1880, p. 149. 

f Ziemssen's " Cyclopaedia," vol. iv. 

X " Report of Cases of Fibrinous Bronchitis," by Dr. Glasgow. 



CROUPOUS BRONCHITIS. 



467 



bronchitis, with chilliness, fever, general malaise, a troublesome cough, 
soreness of the chest, and oppression. These symptoms continue for 
several days, when more formidable troubles are manifested by an in- 
creasing dyspncea, " livid, swollen countenance," * high fever, rapid 
pulse, a dry, harsh, and resonant cough, anxiety, and sometimes haemop- 
tysis. There may be no preliminary symptoms of acute bronchitis 
merely, but the disease set in at once by severe difficulty of breathing, 
preceded by a rigor, and accompanied by high fever. At first the ex- 
pectoration is that of bronchitis, but in a few days the characteristic 
casts are brought up with a good deal of coughing and straining. There 
may be then immediate relief afforded, the dyspnoea subsiding and the 
cough becoming much less severe. In the course of a few hours, or a 
day or two, there may be a recurrence of the severe dyspnoea and the 
straining cough, and more casts will then be discharged. More or less 
haemorrhage may occur, or masses of bloody mucus may be expecto- 
rated. In the chronic form of croupous bronchitis, there is usually a 
history of chronic bronchial catarrh, or of some form of pulmonary dis- 
ease. During the course of such disease, acute bronchial symptoms 
come on, fever, dyspnoea, and a most severe straining cough, cyanosis, 
anxiety, etc., during which casts of the tubes are expectorated. Then 
the symptoms subside, and afterward only those symptoms pertaining 
to the chronic malady are experienced, until there occurs a return of the 
paroxysms. In some cases, during a long time — a year — there may be 
discharged every few days casts ; in other cases the attacks may occur 
two or three times a year, f When the attacks happen at longer inter- 
vals, the symptoms are apparently more acute and severe. 

Course, Duration, and Termination. — The acute cases run their 
course in a few days. The fatal cases may terminate within the first 
week, as early as the fourth day, and none continue longer than two 
weeks. About one half of the cases terminate fatally. In the fatal 
cases the casts either remain in situ or are in part discharged, or are 
reproduced. The cyanosis rapidly deepens, carbonic-acid poisoning 
supervenes, the dyspnoea augments, and the patient dies asphyxiated. 
The chronic form pursues a different course. The attacks recur from 
time to time, during the prolonged existence of a chronic bronchitis, 
and a fatal result is reached in an acute attack with symptoms of as- 
phyxia, or by the changes belonging to the associated malady. Other 
cases are connected with phthisis, emphysema, etc., and pursue a simi- 
lar course, death occurring usually in an acute suffocative attack. 

Diagnosis. — Until the characteristic casts have been discharged, it 
will be impossible to distinguish these attacks from those of capillary 
bronchitis. As there are no symptoms of laryngeal stenosis, bronchial 
will be readily separated from laryngeal croup. A careful considera- 

* " Transactions of the Pathological Society," vol. xi, p, 23. 
t Ibid., p. 24. 



468 



DISEASES OF THE RESPIRATORY ORGANS. 



tion of the history of the case will prevent this disease being con- 
founded with a foreign body in the air-passages, the symptoms being 
much the same in both. It is to be distinguished from catarrhal 
pneumonia by the changes in the sonority of the lungs caused by the 
latter, but a suspension of judgment will be necessary until the casts 
are expectorated in those cases of croupous bronchitis occurring in the 
course of chronic pulmonary affections. 

Prognosis. — Opinions must be expressed with caution in any case 
of the acute type, as fifty per cent, prove fatal. In chronic cases the 
prognosis is grave, because in so many of them lesions exist, which 
must eventually destroy life. The prognosis is favorable, however, in 
the chronic cases without complications, as recovery takes place in a 
majority of them. The prognosis is rendered grave by these indica- 
tions : severe dyspnoea, cyanosis, stupor, high fever, great extent of 
the surface affected in the lungs, the extremes of age, little vigor of 
constitution, and bad hygienic surroundings. 

Treatment. — As the extreme urgency of the symptoms depends 
largely on the obstruction by the false membrane preventing the access 
of air, the first requisite is to dislodge and remove this obstruction. 
Active emesis is the most effective means for immediate result, and the 
most efficient emetic is apomorphine, which should be injected hypoder- 
matically. Next to this is the subsulphate of mercury, which acts 
promptly without producing depression. Tartar emetic is too depress- 
ing, but it may be employed in the absence of the other agents. Sul- 
phate of zinc is safe and effective. The repetition of the emetic is 
determined by the dyspnoea and cyanosis. Softening the false mem- 
brane by inhalation of the vapor of water, especially of lime-water, is 
highly serviceable. Merely disengaging steam in the apartment is 
useful, but the utility of the application is greatly enhanced by the 
addition of lime. The domestic method of producing vapor and ato- 
mizing lime is an excellent plan. This consists in slaking freshly- 
burned lime, the patient inhaling the vapor as it arises. Lime-water 
may be atomized in the ordinary way. Such softening and solvent 
applications should precede the emetic. 

Great good has been accomplished in these cases by the adminis- 
tration of the iodides, with alkalies. The author strongly urges the 
use of the iodide and carbonate of ammonia, in small doses every hour 
or two. It is highly important to prevent a recurrence of the seizures. 
Remedies having a direct effect on the bronchial mucous membrane, 
because eliminated by it in part, at least, afford the best prospect of 
relief. These remedies are the iodides, the balsams and oils, as copaiba, 
turpentine, eucalyptol, etc., which should be perse veringly administered 
for a long time. The effect of these remedies is aided by arsenic, which 
should also be given persistently. The complications of croupous bron- 
chitis should be treated in accordance with the requirements of each case. 



STENOSIS OF THE BRONCHI. 



469 



STENOSIS OF THE TRACHEA AND BRONCHI. 

Definition. — By stenosis is meant a narrowing or contraction of the 
trachea or bronchi, produced by obstruction within and by pressure 
from without. 

Causes. — The trachea or the bronchi are narrowed by interior ob- 
structions and by exterior pressure. In the second group are in- 
cluded enlarged thyroid or goitre ; swollen lymphatic glands at the 
hilus of the lungs and the bifurcation of the trachea ; aneurism of 
the arch of the aorta, especially of the concave and posterior arch ; 
tumors, abscesses, etc., of the mediastinum ; and cancer of the lung. 
In the first group are cicatrices, indurations, and adhesions ; neo- 
plasms or new formations ; inflammation and thickening of the 
walls, etc. 

Symptoms. — So far as the symptoms are concerned, the cause of 
the obstruction is of little moment. The most obvious symptom of 
stenosis is difficulty of breathing, but not the kind of difficulty pro- 
duced by emphysema, capillary bronchitis, etc., which is expiratory, 
whereas that due to this disorder is inspiratory. When there is great 
difficulty, all of the accessory muscles of respiration are brought into 
action to fill the lungs, but expiration is easy and unobstructed. Not- 
withstanding the strong efforts put forth to fill the lungs, this is not 
accomplished, and hence more or less rarefaction of the air in the 
lungs takes place, so that on inspiration, instead of expanding, certain 
parts of the chest are drawn in, viz., the lower part of the sternum 
and the inferior ribs. The movements of the larynx are very slight in 
tracheal and bronchial stenosis, and very free in stenosis of the larynx. 
A peculiar whistling, wheezing, crowing, or musical note is produced 
by stenosis, and the sound of expiration is higher in pitch than that 
of inspiration. If the obstruction is sufficiently high up in the tra- 
chea, the vibration in the column of air may be transmitted to the 
walls of the organ, producing a defined thrill. The voice is weak and 
muffled, because of the interruption in the passage of air to the vocal 
cords. The vesicular murmur is also weakened, obscured by the tra- 
cheal or bronchial sounds, or absent. This change may exist in one 
lung only, if a bronchus is obstructed. If the stenosis is in one bron- 
chus only, the movements of the corresponding side of the thorax are les- 
sened ; the vesicular murmur is diminished, obscured or abolished, and 
there are loud whistling, sonorous, and wheezing sounds, with more or 
less thrill, while the sonority of the corresponding lung is undiminished. 
The healthy lung having an increased amount of work to do, there is 
more or less expansion, the movements are also greater, and the dia- 
phragm is pushed down somewhat. A laryngoscopic examination 
separates laryngeal from tracheal stenosis, and under favorable circum- 
stances indicates the position and character of the latter. The ration- 



470 



DISEASES OF THE RESPIRATORY ORGANS. 



al symptoms are those of difficulty of breathing and obstruction to the 
entrance of air. The face is anxious, the alae of the nose work, the 
skin is covered with a sweat, and there is constantly present a sense of 
the need of air. Besides this constant difficulty of breathing, the 
severity of which depends on the amount of the stenosis, there now 
and then occur acute exacerbations of dyspnoea, due either to a fresh 
catarrh, to a sudden increase of the compressing force, but especially 
to an asthmatic attack. The ordinary rate of difficulty of breathing 
may continue uniform for a long period ; but toward the end suffo- 
cative attacks come on, which are at first separated by considerable 
intervals of time, but become nearer gradually, and life is ended by 
them, or by an intercurrent pneumonia. 

Course, Duration, and Termination. — The clinical history is usually 
divided into three stages : the first consists of the disturbance pro 
duced by the growth of the obstruction ; the second, the period of 
difficulty of breathing and the other symptoms due to the completed 
obstructing cause, which may continue for a long time ; the third, 
consisting of the final suffocative attacks. The duration is protracted, 
and can not be expressed in definite numbers. The ultimate termina- 
tion of a large proportion is death ; many cases may continue for years 
without apparently interfering with health, but these are exceptional 
cases. Cerebral symptoms — coma — may appear toward the end. Death 
may be caused by pneumonia, oedema of the lungs, etc. Sometimes 
death occurs suddenly without the warning afforded by severe dysp- 
noea, caused by the rupture of an aneurism, of an abscess, or rarely 
without any apparent cause. 

Treatment. — The therapeutical management is concerned with the 
cause of the stenosis, and need not, therefore, be considered here. 

ASTHMA. 

Definition. — This term has been applied to various morbid states, 
characterized by spasmodic difficulty of breathing, but it should be 
restricted to an independent, substantive affection occurring paroxys- 
mally, without any morbid alteration of the breathing organs, and con- 
sisting in acute dyspnoea, lasting some hours, and terminating in 
health. It is appropriately divided into the idiopathic and sympto- 
matic. 

Causes. — Various theories of asthma have been proposed. With- 
out occupying space with details, it will suffice to state that asthma 
is a neurosis of the breathing apparatus, and like other neuroses 
arises from sources of disturbances in the nervous system, central and 
peripheral. Like other neuroses, the conditions of the nervous system 
necessary to its development may be inherited. Nothing is more com- 
mon than the occurrence of this malady in different generations and 



ASTHMA. 



471 



branches of a family — the author has known of many examples. 
Asthma alternates with other nervous affections — with hemicrania, 
epilepsy, and angina pectoris. Asthma also alternates with affections 
of the skin — with urticaria, for example ; and succeeds to eruptions of 
the skin, of the herpetic kind (Waldenburg). The pressure of enlarged 
lymphatics on the pneumogastric nerve has excited attacks. Various 
peripheral irritations induce asthmatic seizures. Evil intelligence, the 
association of ideas as connected with particular localities, and other 
moral causes, will excite attacks. Curious examples are related in 
regard to the influence of local associations : thus attacks occur 
on one floor of a house, and not another ; on one side of a street, 
and not the other, etc. Distention of the stomach, indigestion, and 
flatulence, nasal polypi, certain odors, dust of a peculiar kind, pollen 
of plants, etc., will excite attacks. The mechanism is plain. In 
the case of intestinal irritation, the end-organs of the pneumogas- 
tric are acted on, the impression is communicated to the pneumogas- 
tric nucleus, and reflected over the bronchial and pulmonary branches 
of the vagus. In the case of affections of the nasal mucous mem- 
brane, the filaments of the fifth nerve receive the impression, and^ 
as the nucleus of the fifth and of the pneumogastric lie in close juxta- 
position, and are intimately associated in function, disturbance in 
the one is easily and quickly transferred to the other. Of this rela- 
tion numerous examples exist. Asthma is more common in men than 
in women : according to Hyde Salter, of one hundred and fifty-three 
asthmatics tabulated by him, one hundred and two were men, and 
fifty-one were women. The disproportion is greater in advanced life. 
Asthma is common in childhood and up to ruiddle age, but occurs at 
all ages. It is rather more common among the well-to-do classes. 
Surroundings have but little influence, unless a predisposition exists. 
Change of locality has a remarkable influence on asthma, but the con- 
ditions of climate which prove favorable are most diverse. Some do 
better in the heart of a great city, others on a dry and elevated pla- 
teau, others in a humid valley. Mental and moral influences are more 
potent than mere climatic peculiarities. 

Pathogeny. — As asthma is a neurosis, there are no anatomical 
changes peculiar or essential to it. There are, it is true, morbid states 
associated with, but are not necessary to it. Bronchial catarrh is often 
found, also emphysema, but these are sequelae or results, rather than 
a part of the disease. During the existence of the asthmatic paroxysm, 
an intense congestion has been seen on laryngoscopic examination. 
There are, at present, two dominant theories of the pathogeny of the 
asthmatic seizures ; the theory of tonic spasm of the diaphragm^ pro- 
pounded by Wintrich ; the theory of spasm of the bronchial muscles, 
which is the oldest theory, but has the support of Salter, "Williams, and 
Trousseau, and is now sustained by the remarkable investigation of 



472 



DISEASES OF THE RESPIRATORY ORGANS. 



Professor Paul Bert. The new theory of Leyden * has attracted at- 
tention by its singularity. He finds in the expectoration brownish 
cells undergoing granular degeneration, between which are colorless, 
extremely small but pointed, octahedral crystals, some readily visible, 
others requiring immersion lenses to find them. These crystals have 
been examined by Salkowski,f with the result to show tjiat they must 
be composed of a material analogous to mucin. Leyden supposes the 
asthmatic paroxysm to be determined by a reflex spasm of the muscles 
of the bronchial tubes, induced by the irritation of the terminal fila- 
ments of the vagus by these minute crystals. A more recent and the 
latest theory is that of Weber (Riegel I ), which supposes the concur- 
rence of a number of factors in causing asthma, such as bronchial 
spasm, catarrh of the tubes, tonic spasm of the diaphragm, cardiac 
lesions, etc., which is, in fact, a combination of the previous theories, 
and is, probably, the nearest approach to a true hypothesis in that it 
adopts all the presumed causes. 

Symptoms. — The first attack is sudden, but the succeeding attacks 
are preceded by prodromes, the significance of which presently be- 
comes apparent to the sufferer. These prodromes are usually acute 
coryza, some bronchial irritation, headache, and general malaise ; or 
the preliminary symptoms may be those of indigestion — acidity, pyro- 
sis, flatulence, hiccough, sneezing, etc. The first attack is nocturnal. 
The victim, after some uneasy sleep, is suddenly aroused by an intense 
anguish in his chest ; he is stuffed up and struggles for air, jumps from 
the bed and rushes to the window, or he sits up, leaning forward on his 
arras, and uses all his strength in the effort to get more air. The 
breathing is accompanied with loud wheezing, the face becomes flushed 
and at the same time cyanosed, and is bathed in perspiration, the 
eyes stare, the eyeballs protrude, and the muscles of the neck start 
prominently up, as they are called on to aid in the effort to get air. 
The difficulty of breathing soon reaches a point that the inspiration is 
nothing but a gasp, the lips become pallid, the cyanosis deepens, and 
it appears to the patient that every minute must be his last. After 
some minutes or hours the respiration becomes a little easier, more air 
enters the lungs, the cyanosis subsides, and gradually the paroxysm 
ceases. Eructations of gas give great relief as the breathing becomes 
easy, and the bronchial tubes pour out an abundant mucus secretion, 
the expectoration of which also contributes to the ease of respiration 
now rapidly increasing. A free urinary discharge also takes place, the 
urine being pale, and of low specific gravity. The patient, exhausted 
with the violence of his efforts to get air, sinks into a profound sleep, 
and is bathed in perspiration. The whole duration of an attack rarely 

* Virchow's " Archiv," vol. liv, p. 324, " Zur Kenntniss des Bronchial-Asthma." 
\ Ibid., p. 344. 

X Ziemssen's " Cyclopaedia," vol. iv. 



ASTHMA. 



473 



exceeds six hours, and may, indeed, be no more than one hour. On 
the following day there are experienced muscular soreness, languor, 
and debility, but all unpleasant feelings subside and disappear in 
twenty-four hours, and a normal condition is maintained until the next 
attack. Instead of a single paroxysm there may be only slight remis- 
sions, and one attack succeed to another, with exacerbations, so that 
the patient can not lie down at all, can take but little food, and is, after 
some days of suifering, utterly exhausted. The attacks are not exclu- 
sively nocturnal, but do sometimes occur during the day. A diurnal 
attack must be the rule in those cases brought on by the inhalation of 
some kinds of dust, gas, or vapor, as from powdered ipecac, etc. On 
percussion, the sonority of the thorax is increased in the vertical 
diameter from one to two inches, and also transversely, and does not 
change either on inspiration or expiration. The percussion-note is 
highly resonant all over both lungs, and has somewhat the tympanitic 
quality. The "bandbox-tone," by which it is described by Bam- 
berger, is eminently characteristic. The vesicular murmur is either 
absent or greatly enfeebled, or obscured by the loud, wheezing, whis- 
tling, sibilant sounds. During expiration the sibilant, sonorous, whis- 
tling, cooing, sighing sounds are more pronounced and of longer dura- 
tion. Toward the close of an attack moist sounds occur. The expla- 
nation of the physical signs present in an attack of asthma is afforded 
in the condition of the chest. The diaphragm is depressed below its 
ordinary position by tonic contraction ; the chest, which assumes a dis- 
tended, globular shape, is fixed in the position of forced inspiration. 
The lungs are filled with air, but it is residual air, and is not renewed ; 
and, notwithstanding the effort put forth by the patient, the little air 
which can be introduced only adds to the distention. Expiration is 
prolonged, laborious, wheezing, and much more so than inspiration. 
Spasm of the muscular fibers of the bronchi is perhaps only one ele- 
ment in the obstruction to the expiration of air ; tonic contraction of 
the diaphragm contributes not a little to the result. The fullness of the 
cephalic veins and the cyanosis and lividity of the face are due to the 
contraction of the cervical muscles preventing the return of blood, and 
to deficient oxygenation of the blood. While the face is flushed and the 
head hot, the feet are cold. The sputa are wanting in the beginning, 
but appear abundantly at the close of the paroxysm ; they are frothy, 
grayish- white, or reddish -white if mixed with blood, and consist of 
mucus corpuscles, cylindrical and ciliated epithelium, and peculiar 
" yellowish-green clumps " in which are imbedded Leyden's crystals. 

Course, Duration, and Termination. — Asthma is an essentially 
chronic disease, not incompatible with long life, and with good, even 
vigorous health, during the intervals between the seizures. The par- 
oxysms last from two to six hours, but sometimes they persist for 
days. Of itself, asthma is never fatal to life, but changes in the or- 



474 



DISEASES OF THE RESPIRATORY ORGANS. 



ganism are gradually effected by the disturbance in the respiratory 
function, which may cause death. Emphysema, dilated right cavities, 
dropsy, or cerebral haemorrhage, may be brought on by the long-contin- 
ued operation of the cause. Much depends on the number of the par- 
oxysms. There may be very few or very many. They may be mild 
at first, and become more severe, or they may commence and persist 
with the greatest severity. They may disappear suddenly, and never 
occur again. According to the behavior of the disease will vary the 
sequelae. Asthma may also occur as a complication of some existing 
disease — as, for example, emphysema, chronic bronchitis, etc. 

Diagnosis. — It is not possible to mistake asthma when the history 
is known. The first attack may be confounded with oedema of the 
glottis or spasm, paralysis of the vocal cords, and stenosis of the trachea. 
Laryngoscopic examination may serve to differentiate at once, by 
recognition of the lesion. The most important means of determining, 
besides the history and the direct exploration of the larynx and trachea, 
is the character of the dyspnoea. In laryngeal or tracheal obstruction, 
the dyspnoea is inspiratory ^ in asthma it is expiratory. In oedema of 
the glottis, while inspiration is difficult, expiration is easy and unob- 
structed ; with inspiration there is a loud sibilant or crowing noise, 
and expiration is silent. 

Treatment. — To relieve the paroxysm is the most pressing duty. 
There is no medication so effective as the hypodermatic injection of 
morphine (from -^^ gr. to J gr.). An efficient dose of chloral hydrate 
is often equally effective (3j — 3 ss.). As soon as the patient comes 
under the influence of either remedy, the difficulty of breathing begins 
to subside. The best results are obtained from a combination of the 
two remedies — morphine hypodermatically and chloral by the stomach 
— but in smaller quantity than when administered separately. Nitrite 
of amyl (by inhalation, three to five minims) sometimes affords relief, 
but nitro-glycerine solution by the stomach is far more effective, and is, 
indeed, a highly useful remedy. In many cases iodide of potassium, in 
full doses, will arrest the paroxysms very remarkably. From fifteen to 
twenty grains, every two, three, or four hours, are usually required. It 
is better practice to give iodide with bromide of potassium, and to each 
dose of the solution may also be added a drop or two of Fowler's solu- 
tion of arsenic. This combination is to be commended, especially in 
the cases which persist for some days. Much relief is afforded by fumes 
of stramonium and other narcotics ; old asthmatics often depend on 
fumigation to the exclusion of all other remedies. Pastils, or cigarettes 
containing leaves of belladonna, stramonium, tobacco, grindelia, and 
poppy, in equal portions, steeped in a saturated solution of nitre and 
dried, are ignited and the fumes inhaled. Iodide of ethyl inhaled is 
effective, for to the calmative action of ethyl is added the influence of 
an iodide. There are proprietary pastils sold, but, under what name 



ASTHMA. 



475 



soever they appear, the composition, with unimportant differences, is 
about as stated above. Belladonna-leaves saturated with nitre afford 
as good results, usually, as the more complicated pastils. Simple 
nitre-paper gives ease for a time. The new California remedy, grm- 
delia rohusta^ has undoubtedly great power to arrest a paroxysm of 
asthma. Three to five grains of the extract or the fluid extract ( 3 ss.) 
can be given every hour or two. Grindelia is often useful as a fumi- 
gant. The debility caused by asthmatic paroxysms is best removed 
by quinine and iron, the former in considerable doses. This practice 
is especially to be commended when the paroxysms recur frequently. 
To prevent a return of the attacks, arsenic is very useful, and is most 
effective in combination with the iodides. In debilitated subjects, 
quinine, arsenic, and belladonna may be given steadily for some weeks 
or months, as the case may be. Asthma, like other neuroses, is capri- 
cious in its behavior toward remedies. The remedy succeeding at one 
time may fail utterly at another time, so that the treatment must be 
varied accordingly. Hence it is necessary to be fertile of resources 
in the treatment of this disease. Besides the methods of treatment 
already mentioned which are most approved, there are others less de- 
sirable which should receive some notice. Nauseants, as ipecac, tartar 
emetic, and lobelia, afford relief by inducing relaxation consequent 
on the nausea. When there is much catan*h, or the attack of asthma 
is due to an acute catarrh, good results are obtained by small doses of 
tartar emetic (y^g gr.) with morphine (y^. A few drops of wine of 
ipecac (five to ten) every five minutes, until some nausea is experi- 
enced, may lessen the oppression remarkably. During the paroxysm, 
nauseant doses of lobelia (TT[ xv — 3 ss. of the fluid extract) are very 
effective in stopping the dyspnoea. Recently quebracho has been 
brought forward as a remedy for dyspnoea, which it often surprisingly 
relieves. From twenty minims to 3 j of the fluid extract may be 
given every hour or two until relief is had. 

The application of ammonia to the posterior wall of the pharynx is 
practiced by the French, but this practice is strongly condemned by 
Jaccoud. He, however, permits the application of ammonia by im- 
pregnating the air of the apartment. The inhalation of oxygen and 
of compressed air relieves the breathing somewhat, but ether and 
chloroform are much more effective. Ethyl bromide has lately proved 
remarkably effective by inhalation. 

In the treatment of asthma there is no point of greater importance 
than careful regulation of the diet. Hyde Salter much insists on this, 
and the author has had abundant confirmatory observation. The diet 
should be light and easily digestible, and as little bulky as possible. 
It should consist, therefore, chiefly of animal food, and to this may be 
added a little fruit and a few of the succulent vegetables, but starchy 
and saccharine substances and milk should be excluded. In this pro- 



476 



DISEASES OF THE RESPIRATORY ORGANS. 



hibition bread is included, as it is particularly apt to disagree. Articles 
of diet that are fried, pastry, cakes, and sirup, etc., are highly objec- 
tionable. Meats should be broiled or roasted. Boiled meats and soups 
are improper. There should be as little fluid drunk at meals as pos- 
sible, but a little black coffee may be allowed at breakfast. 

DISEASES OF THE LARYNX— ACUTE CATARRH OF THE LAR- 
YNX—LARYNGITIS. 

Definition. — By acute catarrh of the larynx is intended an inflam- 
mation involving the mucous membrane — a catarrhal inflammation. 
There is also a chronic form of the disease — chronic inflammation. 

Causes. — The mucous membrane of the larynx is in a position to be 
quickly and easily affected by external agents of a gaseous or aeriform 
kind — such as ammoniacal gas, chlorine, tobacco-fumes, etc. Very fine 
solid particles may be carried in the air in suflicient quantity to excite 
an irritation of the laryngeal mucous membrane. But the organ is 
more frequently affected by the condition of the atmosphere itself. 
The long-continued insj)iration of air contaminated by respiration is 
very apt indeed to cause congestion of the mucous membrane, espe- 
cially when to this is added the sudden contact of cold air. Too pro- 
longed exertion of the voice may also excite a catarrhal inflammation, 
especially when the exertion is made in the open air. " Taking cold " 
is a fruitful cause of laryngitis. There may be an extension of trouble 
from the pharynx and from the face (erysipelas). Influenza may ex- 
tend to the mucous membrane of the larynx. Inflammation of the 
larynx is not an infrequent complication in the course of the infectious 
diseases. Climate has an unquestionable influence ; humid, cold, and 
variable climates increase the disposition to affections of the larynx, 
while warm and equable climates lessen the tendency to these diseases. 
Affections of the larynx occur at all ages, and both sexes are equally 
liable in proportion to their exposure to the causes. 

Patholog'ical Anatomy. — In the mildest cases there is a transient 
hypersemia of the mucous membrane — in certain situations — over the 
arytenoid cartilages, the ventricular bands, the posterior ends of the 
vocal cords, and the space between the arytenoid cartilages. In more 
severe cases there is a good deal of swelling as well as injection of the 
ventricular bands, the epiglottis, the ary-epiglottidean folds, and the 
inter- arytenoid space, etc. The color in severe cases, instead of being 
reddish, is a dark, reddish-brown. 

Symptoms. — In the mildest cases there is no constitutional disturb- 
ance. The local symptoms consist in heat, rawness, and tickling, re- 
ferred to the larynx and pharynx. When the thyroid cartilages are 
pressed, unusual soreness, irritation, and severe pain are experienced. 
There are also present dryness, and a feeling of a foreign body stick- 



LARYNGITIS. 



477 



ing in the throat. Swallowing causes pain by the upward movement 
of the larynx, and by the pressure of the bolus on the larynx as it de- 
scends to the stomach. In the more severe cases the onset of the dis- 
ease is announced by some chilliness and general malaise, followed by 
moderate fever, anorexia, etc., for several days. Cough occurs at once, 
and it is noisy, harsh, hoarse, or toneless ; or, in children especially, 
has a ringing, sonorous, so-called " croupy " character. The cough is 
dry, and produces a sensation in the larynx as of scratching over a 
raw surface ; but in a short time secretion is poured out, and then the 
cough has a loose character. At first some frothy mucus is expecto- 
rated ; it may be streaked with blood occasionally, but in the rare 
haemorrhagic form pure blood may be expectorated. The sputa soon 
assume the appearance of muco-pus, the pus elements predominating ; 
and it contains also cast-off ciliated epithelium, young cells, etc. At 
first the voice is thick, and becomes hoarse on talking ; but as the case 
progresses the hoarseness deepens, and at length there is aphonia. 
Dyspnoea rarely occurs to adults in simple mucous laryngitis, but in 
children spasm of the glottis may come on, when there is extreme 
dyspnoea in brief paroxysms. But, as this disorder will be discussed 
in a separate section, its consideration as a symptom of laryngitis is 
postponed. A sense of oppression and need of air is caused if there be 
much swelling of the vocal cords or ventricular bands in the case of 
adults — a condition of things not apt to occur unless there be some 
effusion into the sub-mucous connective tissue. Besides hoarseness, 
which may end in aphonia, there may be various alterations in the 
tone of the voice, high pitch or low pitch, and its timbre may be 
subjected to corresponding variations. The peculiarities of voice are 
due to swelling of the mucous membrane, variations in tension of the 
vocal cords, and the condition of the muscles moving the arytenoid 
cartilasces. The tone of voice is hoarse and roush from swellino; of 
the cords, discordant from the difference in the rate of vibrations of 
the two cords, high-pitched if the tension in the cords is great, low- 
pitched if the tension is low ; or there is a double tone, now high, now 
low, if the cords vibrate with opposite tension. On laryngoscopic 
examination the state of the mucous membrane, of the vocal cords, 
ventricular bands, etc., can be made out, and the changes described 
verified. 

Course, Duration, and Termination.— Acute laryngitis passes through 
its course in a week, if mild ; but the more severe cases may occupy 
three weeks to a month. Mild as well as severe cases may continue 
indefinitely by repeated relapses, and at last assume the chronic form. 
Under some circumstances a simple laryngitis may assume formidable 
proportions by the extension to the sub-mucous connective tissue. 

Treatment. — Confinement to bed for the more severe cases, and to 
a uniformly but not too highly warmed ap.artment for the milder cases, 



478 



DISEASES OF THE RESPIRATORY ORGANS. 



is essential. The air of the apartment should be kept moist by the 
vapor of water disengaged in it. For the relief of the inflamed mu- 
cous membrane, tincture of aconite-root — one drop for a child and two 
drops for an adult every two hours — is highly eflicient. If there be 
much cough, and especially if the cough have the " croupy " character, 
two to five drops of the deodorized tincture of opium and one or two 
drops of fluid extract of ipecac may be given together. Application 
by spray douche of a solution of morphia to the throat is an excellent 
means of relieving cough, but is not so generally available as the inter- 
nal administration. A very minute quantity of tartar emetic, with 
paregoric and sirup of lactucarium, is also an efficient combination. 
A hot or cold pack should be wrapped about the throat after a brief 
application of mustard ; and, if the case is just beginning, the feet 
should be placed in a mustard foot-bath. If there be a tendency to 
spasm of the glottis, bromides should be used. Bromide of potassium 
may be given with any of the combinations above mentioned. 

Prophylaxis is very important in the case of those who have fre- 
quent attacks, especially if a phthisical tendency exists. They should 
wear flannels and protect the feet against dampness, while at the same 
time they should avoid warm wrappings, especially furs about the 
throat. The tendency to take cold may be obviated by a daily morn- 
ing cold sponge-bath, and by keeping up the general health. During 
a variable season, taking cold may be prevented by the daily morning 
administration of five to ten grains of quinine, and the access of an 
impending attack may be prevented by a full dose of quinine and 
morphine (15 grs. — gr. J— J). 

CHRONIC LARYNGITIS— CHRONIC CATARRH OF THE LARYNX. 

Deflnition. — Chronic laryngitis is an inflammation of the mucous 
membrane, less active in type than, but the same in mode as, the acute 
inflammation. 

Causes. — The chronic form of catarrhal inflammation of the larynx 
arises under the same conditions as the acute form, or it succeeds to 
an acute, or is a result of repeated acute inflammation. Tobacco- 
smoking, spirit-drinking, and careless use of the vocal organs in speak- 
ing, reading aloud, or singing, are all influential causes, the most impor- 
tant, in fact, in our day. The middle period of life and the male sex 
are predisposing causes. 

Pathological Anatomy. — The changes described as occurring in the 
acute form are the initial lesions in the chronic, except that in the lat- 
ter the color is deeper red or brownish, the mucosa is more swollen, 
and the subraucosa as well as the mucosa is thickened and indurated. 
Swelling of the inter-arytenoid fold of mucous membrane and of the 
ventricular bands (false vocal cords) occurs to the degree that the 
movements of the arytenoid cartilages are interfered with, and conse- 



LARYNGITIS. 



479 



qiiently of the vocal cords also. The epiglottis is likewise swollen 
and thickened, and marked by enlarged and varicose veins. The vocal 
cords themselves are injected, and their margins roughened. The 
follicles of the mucous membrane are enlarged by accumulation of 
their contents in part, but much more by hyperplasia of the surround- 
ing connective tissue. The enlarged follicles or glands, more or less 
thickly distributed over the surface, give to the mucous membrane a 
granular appearance. Very rarely hyperplasia of the connective tis- 
sue underlying the vocal cords takes place ; the new tissue contracts, 
and deformity, with stenosis, is the ultimate result. 

Symptoms. — Various uneasy sensations are felt in the larynx — a 
sense of heat, and an irritation compounded of itching and scratching 
of a tender surface ; this leads to hawking and clearing the throat as 
if some obstruction were present. Exposure to cold air increases these 
sensations, but still more irritating is prolonged talking, especially in 
the open air, leading to frequent swallowing of saliva. The voice is 
husky, and becomes so much so by talking that frequent efforts to 
clear the throat are necessary. The voice becomes hoarse, rasping, 
and deep, or it is high-pitched, and unexpectedly drops into falsetto. 
As much effort is necessary to get out the sounds, these patients ac- 
quire a straining tone and manner, and now and then, amid husky and 
hoarse, almost toneless sounds, they utter a more distinct and intelligible 
sound, giving an eccentric and variegated expression to the conversa- 
tion. The effort required makes talking very fatiguing. In the morn- 
ing the most severe paroxysms of coughing and straining are experi- 
enced ; the secretion accumulates during the night, and it is detached 
with difficulty, so that much coughing, hawking, and straining are 
necessary. The secretion is in the aggregate not considerable, and 
consists of a tenacious mucus, with some pus-corpuscles. 

Course, Duration, and Termination.— It is a very chronic malady 
and is subject to exacerbations and remissions. Care in the manage- 
ment of the organ, and of the general health, rest, and appropriate 
treatment, bring relief, but abuse of the organ, irregularities of life, and 
the absence of all treatment, will restore the diseased state to full ac- 
tivity. Years may be passed in this way, the general health mean- 
while not suffering from the laryngeal disease. Cures may be effected 
in favorable cases, if proper treatment is carried out faithfully for a 
sufficient period of time, but the difficulties in the treatment, the self- 
denial to be practiced, and the duration of the case, should not be con- 
cealed from the patient. 

Treatment. — Any effective treatment must include local applica- 
tions, directed by the laryngeal mirror and by spray. As there is a 
large extent of surface involved, and as the increased blood-supply is 
the leading pathological factor, the application of medicated spray may 
be sufficient of itself. A great number of medical agents are so em- 
ployed—a solution of tannin (gr. v — 3 j), of sulphate or acetate of 



480 



DISEASES OF THE RESPIRATORY ORGANS. 



zinc (gr. j — ^ j), of chlorate of potassium (gr. v — 3 j), of bromide of 
potassium (gr. x — 3 j), of nitrate of silver, with care (gr. j — § j), and 
of morphine sulphate if there is much irritability. Solution of nitrate 
of silver is applied by the brush directly to the interior of the larynx. 
Ziemssen recommends in inveterate cases the solid nitrate, which is 
applied by the caustic-holder directly. Such external applications as 
the tincture of iodine, the ointment of the red iodide of mercury, etc., 
are serviceable as counter-irritants. The larynx must be kept at rest 
as long as practicable. Taking cold, sudden changes of temperature, 
exposure to draughts, must be avoided. The general health must be 
maintained by a suitable mode of life. Change from a variable to a 
more equable, and from a humid and cold to a warm and dry climate, 
will often have a most favorable effect on the case. 

CEDEMA OF THE GLOTTIS— INFILTRATION OF THE LARYNX. 

Definition.— (Edema of the glottis means a serous effusion into the 
sub-mucous connective tissue. The disease or condition intended by 
this term is an obstruction to breathing produced by an infiltration 
of the larynx by any kind of fluid. 

Causes. — An inflammation of the mucosa may extend to the sub- 
mucosa, and cause oedema. A deep-seated phlegmon of the neck, or 
of the tonsil and the base of the tongue, may involve the larynx by 
the diffusion of the pus under the mucous membrane. An inflamma- 
tion of the cartilages or of the perichondrium may result in a similar 
purulent inflltration. Erysipelas of the face, typhoid fever, or scarla- 
tina, may be unexpectedly terminated by a sudden effusion into the 
sub-mucous connective tissue. During the course of Bright's disease, 
oedema of the glottis may occur, or this may be the first symptom of 
the malady to attract attention. 

Pathological Anatomy.— The oedema exists in those parts containing 
the most abundant and loose connective tissue — in the ary-epiglottic 
folds, the glosso-epiglottic ligament, at the base of the epiglottis, and 
in the inter-arytenoid space. When the inferior or true vocal cords 
are inflamed (one or both), the cord changes its color, and instead of 
appearing white, glistening, and brilliant, is dull, grayish-red, or violet- 
red, in patches, the vessels enlarged and varicose. When oedema 
exists without inflammatory changes, the sub-mucous connective tissue 
of the ventricular bands especially, and of the folds mentioned above, 
is distended with a serous fluid, and has the translucent appearance 
of a fish's swimming-bladder. The ventricular bands project forward, 
almost meeting in the median line, and shutting from view above the 
vocal cords. The epiglottis sub-mucous tissue may also be distended 
in the same manner, giving to that organ the same pellucid and semi- 
transparent appearance. If the swelling be due to purulent infiltra- 
tion, the epiglottis, the aryteno-epiglottidean folds, and the ventricular 



LARYNGITIS. 



481 



bands, will be swollen, and present a deeply congested, reddish-brown 
or violet tint, with here and there spots of a yellowish hue. . A very 
considerable collection of pus may form when the base of the tongue, 
or the loose connective tissue beneath the tonsils, and the tissues of the 
larynx are simultaneously involved. A serous infiltration sufficient to 
cause fatal oedema has disappeared in the death-agony, or immediately 
after, leaving but small traces of the mischief to account for the for- 
midable symptoms. 

Symptoms. — Infiltration of the larynx, succeeding either to some 
inflammatory process in the neighborhood or of the larynx itself, or com- 
ing on in the course of some constitutional malady, adds its special 
features to the symptoms of the preexisting disease. These are a sen- 
sation of distress or actual pain in the pharynx and larynx ; painful 
dysphagia ; dyspnoea ; or paroxysms of a suffocative character. The 
sensations referable to the larynx consist of constant oppression as if a 
foreign body were wedged in the organ, and more or less severe sore- 
ness and pain shooting through the whole area occupied by the purulent 
infiltration, if that be the cause of the symptoms. There may be in 
attempts to swallow only a sense of soreness or of obstruction, but in the 
case of inflammation and swelling there will be acute pain. The feel- 
ing of the presence of a foreign body and the accumulation of saliva 
incite the act of swallowing, which is the more painful the more fre- 
quently it is repeated. When there is extensive infiltration, swallow- 
ing may become impossible, and then the saliva is permitted to dribble 
from the mouth. At first the cough is dry, rather harsh, and somewhat 
resonant, but as the swelling proceeds it becomes stridulous and sup- 
pressed. The peculiar difficulty in inspiration is the most character- 
istic symptom. At first a slight sense of stuffing of the larynx and 
huskiness of the voice are experienced, but the sensation of stuffing 
grows tighter, and the inspiration becomes prolonged and with a very 
obvious effort. A hissing, stridulous, somewhat snoring noise accom- 
panies the inspiration, but expiration is easy and noiseless. As the 
inspiration increases in difficulty, all of the muscles needed to expand 
the chest, and the accessory muscles of inspiration also, are brought 
into play. The inspiration is difficult, because, in drawing in the air, 
the swollen mucous folds are brought together in the center, and 
the more strongly the effort is made the more tightly the folds are 
approximated — for, the cartilages of the larynx keeping the lower 
cavity open, where a partial vacuum is created by the expansion of the 
chest, the incoming air pushes the mobile folds of swollen mucous 
membrane before it, and hence, the more powerful the attempts at 
inspiration, the more tightly the folds are wedged into the narrow 
space. Expiration also becomes difficult when the swollen folds be- 
come immovably distended, and fixed in more or less close apposition. 
When this occurs, expiration becomes stridulous, whistling, crowing, 
and difficult, but not usually in the same degree as inspiration. 
33 



482 



DISEASES OF THE RESPIRATORY ORGANS. 



In the more formidable cases, the obstacles to the entrance of air 
may become extreme in a short time, the patient dying asphyxiated. 
In many other cases the group of symptoms just mentioned are varied 
by attacks of suffocative breathing produced by spasm of the muscles 
of the larynx. Excited by cough, by attempts at swallowing, or the 
accumulation of secretion, etc., on a sudden the breathing is arrested, 
the face gets blue, the eyes start from the head, there are wild gasping, 
a terrified expression, and death seems imminent. Death may occur 
in such an attack. Consciousness may be lost, and then the breathing 
may be resumed ; again, in other cases — but usually the paroxysms do 
not proceed so far as unconsciousness — air enters the lungs, and the 
ordinary difficulty of breathing goes on as before. The existence of 
the obstruction can usually be made out by carefully passing the index- 
finger over the base of the tongue, when the swollen epiglottis and 
aryteno-epiglottidean folds may be felt. It is generally impracticable 
to use the laryngeal mirror when the case is well advanced, but, earlier, 
valuable information may be gained by its use. 

Course, Duration, and Termination. — The most acute cases are those 
occurring during the course of some infectious malady, as typhoid. 
The effusion takes place in a few hours, and the patient expires in a 
short time, asphyxiated. Such may be the course in cases of scarlatina 
also. In the more chronic kinds of laryngeal disease, if oedema occur, 
the progress of obstruction is slower ; there may be days passed be- 
tween the first attack of spasmodic dyspnoea and the fatal result from 
the asphyxia of oedema. The duration of infiltration of the larynx 
varies from a few hours to several days. 

Diagnosis. — From the difficult breathing produced by capillary 
bronchitis, emphysema, and asthma, that of infiltration of the larynx 
is distinguished by the important characteristic of difficulty in inspi- 
ration, whereas in the former the difficulty is in expiration. The aid 
afforded by digital exploration and by the mirror, when practicable, 
will enable a diagnosis to be made at once. Passing the index-finger 
carefully over the base of the tongue, the swollen glosso-epiglottic 
folds, etc., can be felt. Croup, or laryngismus stridulus, foreign 
bodies, polypi of the larynx, and aneurisms of the aorta involving the 
recurrent laryngeal nerve, may produce symptoms similar to oedema. 
The attacks of pseudo-croup come on suddenly, occur at night, are 
quickly relieved, and between the paroxysms there is no trouble of 
any kind. The presence of foreign bodies and polypi is determined 
by the use of the laryngeal mirror, and by the difference in the rational 
symptoms. The history of the case, the sudden occurrence of suffo- 
cative attacks after the accidental inhalation of some foreign body, 
and the coming on or cessation of difficult breathing according to the 
position of the object, are characteristics differing from those due to 
oedema. The symptoms produced by laryngeal polypus are of slow 
development, but the mirror enables a view to be had of the growth, 



ULCERATION OF THE LARYNX. 



483 



revealing a condition of the larynx very different from that of 
oedema. 

Treatment. — To open the trachea is necessary if suffocation is im- 
minent, but, before resorting to such, a severe measure, scarification of 
the swollen membrane should be practiced, according to the method of 
Dr. Gurdon Buck, of New York. A scalpel wrapped, but leaving the 
point free, is passed over the tongue, guided by the finger, and when 
the swollen parts are reached the cutting edge is turned against them, 
and free scarifications are practiced. If pus is reached, a free incision 
is necessary to evacuate it. In tbe case of purulent infiltration the 
act of vomiting may, happily, effect a rupture of the depot. Vomit- 
ing, for this purpose, is best induced by the hypodermatic injection 
of apomorphine, since swallowing becomes so difficult in these cases. 
When the infiltration is serous, absorption may be effected by the free 
salivary and cutaneous discharge induced by pilocarpine. From 
grain to -J- grain should be given subcutaneously, usually twice or three 
times in twenty-four hours. Inhalation of ethyl iodide should be fre- 
quently practiced, and the air of the apartment should be kept moist 
by the vapor of hot water. If attacks of laryngeal spasm threaten 
asphyxia, ethyl bromide can be cautiously inhaled with advantage. 
The free exhibition of iodide of potassium — ten grains every two 
hours — is much to be commended in cases of inflammatory character. 
If urjemic in origin, besides the pilocarpus, digitalis infusion should be 
given to stimulate the renal functions, and compound jalap powder to 
cause free intestinal discharges. As the effusion is forming, full doses 
of quinine should be given before the pilocarpus, and subsequently to 
support the vital j)owers reduced by the loss of fluid. Quinine, in full 
doses, is more distinctly serviceable when the infiltrating material is 
pus. If the onset of the disease is inflammatory, and the effusion into 
the submucosa is the result, tincture of aconite-root should be freely 
administered, and quinine should also be given to prevent migration of 
the white corpuscles. As this disease very rapidly depresses the vital 
powers, it is important to supply the system with nutritious aliment 
from the beginning. The careful administration of stimulants is also 
necessary. If swallowing becomes very difficult and but little aliment 
enters the stomach, the amount taken should be supplemented by " rec- 
tal alimentation." Defibrinated blood should be injected into the rec- 
tum, and nutrient enemata should also be employed. 

TUBERCULAR ULCERATION OF THE LARYNX— LARYNGEAL 

PHTHISIS. 

Definition. — Ulceration of the laryngeal mucous membrane is a 
frequent complication of phthisis, and sometimes, indeed, precedes the 
pulmonary lesions. Although a symptom in consumption, its independ- 
ent importance seems to require more elaborate treatment. 



484 



DISEASES OF THE RESPIRATORY ORGANS. 



Causes. — Virchow* suggests laryngeal tuberculosis as the best 
manifestation for the study of true tubercle. Miliary tubercles depos- 
ited superficially readily induce ulceration, but follicular deposits and 
infiltration of the basement membrane cause more extensive and de- 
structive changes. Hence to primary and secondary tubercular depos- 
its are due the ulcerations of the larynx. 

Pathological Anatomy. — Those parts of the larynx affected by 
tubercular ulcerations are most exposed to injury by the performance 
of their proper functions in phonation and deglutition. These parts are 
the mucous membrane of the vocal processes, the vocal cords, inter- 
arytenoid region, the aryteno-epiglottidean ligaments, and the carti- 
lages of Santorini. The most superficial ulcers are flat, with a grayish 
base, and often very extensive from a coalescence of smaller ones. 
These are probably ulcers by corrosion, the ichorous matters from the 
lung-cavities setting up an infection in a part — the seat of a catarrhal 
process. Another form consists in tubercular deposition in the folli- 
cles, disintegration and loss of substance, the resulting ulcer having 
the characteristic "grape-shape" (Rindfleisch). As the follicles lie in 
the sub-mucous connective tissue, it is readily seen how deep must be 
the ulcers thus produced. Extensive excavations result from the 
spread of the destruction laterally and the union of several ulcers. 
These ulcers, forming on the laryngeal cartilages, soon extend to and 
ultimately involve this structure. Still another variety of ulcer is de- 
rived from the disintegration of tubercle granulations deposited in the 
sub-epithelial layer of the mucous membrane. The extent of injury to 
the larynx varies greatly. The mucous membrane of the vocal pro- 
cesses, of the posterior wall of the larynx at the base of the arytenoid 
cartilages, of the vocal cords, and elsewhere, is destroyed. The vocal 
cord may not only be deeply ulcerated but even loosened from its pro- 
cess (Von Ziemssen). The ulcers penetrating to the cartilages set up 
perichondritis, necrosis, and disease of the crico-arytenoid articulation. 
Thus the mucous membrane of the larynx in its entirety may be the 
seat of ulcerations, the sub-mucous tissue becoming (edematous and the 
muscles relaxed and fatty. 

Symptoms. — The earliest implication of the larynx in disease is an- 
nounced by changes in the voice, by hoarseness on making any con- 
siderable and prolonged effort, or on taking a slight cold. The changes 
seen on laryngoscopic examination at this stage are either pallor, anae- 
mia, and paresis of the muscles, or hypersemia, and some swelling of 
the mucous membrane of the inter-arytenoid region, etc. Catarrh of 
the mucous membrane soon comes on, and is followed by superficial 
erosions and flat ulcers in the region first attacked, these solutions of 
continuity being surrounded by a zone of more or less intense hyper- 
gemia. In the further progress of the cases, deep and extensive ulcera- 
* " Die krankbaften Geschwiilste," Bd. ii, p. 645. 



ULCERATION OF THE LARYNX. 



485 



tions occur, the vocal cords becoming ragged, and the edges of the 
ulcers forming irregular excrescences which may and have been mis- 
taken for polypi. The ulcerations extend over the epiglottis and the 
arytenoids, and extensive losses of substance occur in advanced cases 
in the former organ. The weakness and ready failure of the voice 
and the easy occurrence of hoarseness, noted at first, increase in every 
w^ay as the ulcerations extend ; hoarseness presently becomes habitual 
and constant, and finally the voice loses its tone, the patient speaking 
with difficulty in a husky whisper. Paresis of the laryngeal muscles 
and oedema of the sub-mucous tissue are in part responsible for the 
failure of phonation. The pain at first is trifling, a mere sense of heat, 
but, as the cases progress, much soreness and burning are referred to 
the larynx, and are increased by the attempts at swallowing. Fre- 
quent efforts to clear the larynx of the muco-pus and detritus are 
made, with the effect to increase the soreness and burning pain. The 
glottis becoming damaged and the aryteno-epiglottidean folds swelling 
with oedema, as well as damaged by ulceration, the larynx is imper- 
fectly closed in the act of swallowing, and hence, particles of food 
and drink entering it, paroxysms of violent coughing and suffocative 
attacks are provoked. 

Course, Duration, and Termination. — The progress of these cases is 
greatly affected, as might be expected, by the extent of the laryngeal 
disease and of the pulmonary lesions. In some cases of laryngeal 
phthisis, so called, the progress of the disease is due chiefly to the 
extent of the mischief in this organ ; in other cases the pulmonary dis- 
ease is relatively more active. The duration of the laryngeal malady 
is therefore a question of the condition of the lungs. When, by 
reason of the changes in the larynx, swallowing becomes difficult, the 
nutrition suffers because of the failure to obtain sufficient aliment. No 
exact limits can be set as to the duration of the case. In some cases 
the progress of the pulmonary and of the laryngeal lesions is equally 
rapid ; in other cases the lung-disease is slow, and the laryngeal ulcera- 
tions are limited to a few points ; in still others the ulcers of the larynx 
cicatrize, and an apparent arrest of phthisis occurs, to be followed, 
after some years, by a renewed activity in the morbid process. 

Diagnosis. — We have m the laryngoscope an accurate means of 
determining the extent of the ulcerations, and from them to judge of 
the condition of the cartilages and articulations. Varicose prolonga- 
tions of the margins of ulcers may be mistaken for polypi, an example 
of which error fell under the author's notice, as made by a celebrated 
specialist. Careful inspection, the head well extended to bring the 
excavations into view, will enable the observer to get a correct notion 
of the local condition. More frequently the error made by specialists' 
consists in the failure to properly appreciate the condition of the lungs, 
and to ascribe the symptoms solely to the laryngeal lesions. As it is 



486 



DISEASES OF THE RESPIRATORY ORGANS. 



an extremely rare, almost an unknown, event to have laryngeal tuber- 
culosis exist alone, the inability to discover the pulmonary disease 
should make the practitioner cautious in the expression of his beliefs. 

Treatment. — The treatment consists in the application of local 
agents and in appropriate systemic remedies. Guided by the mirror, 
solutions of nitrate of silver, sulphate of zinc, sulphate of morphine, 
carbolic acid, carbolate of iodine, and chlorate of potassium, can be 
applied to the affected area directly. Powders may be thrown in by 
insufflation — as alum, tannin, iodoform, bismuth, etc. Atomized fluids, 
consisting of solutions of the mineral and vegetable astringents above 
mentioned, may also be used. When there is much irritation of the 
larynx, penciling the interior with solutions of bromide of potassium, 
sulphate of morphine, and of cocaine are highly useful. 

The usual means to improve the nutrition of the body are neces- 
sary. Cod-liver oil, the phosphates, and hypophosphites must be freely 
administered. Indeed, the general plan for the treatment of phthisis 
should be followed, as elsewhere laid down. 

SYPHILIS OF THE LARYNX. 

Pathogeny. — Syphilitic lesions of the larynx occur with other mu- 
cous affections in from two to six months after infection. Again, the 
larynx may be affected years after all manifestations have apparently 
ceased, in this respect behaving as syphilis does in any organ which 
may be attacked. The disease is invited to this organ by its func- 
tional uses, and hence occurs in those who employ freely the organ in 
speaking and singing. 

All the various syphilitic mucous lesions occur in the larynx — as 
condylomata, gumma, etc. They ulcerate, destroy the mucous mem- 
brane, and light up perichondritis with ulceration of the cartilages. 

Symptoms. — There is usually but little pain, although some sore- 
ness may be developed by pressure. Hoarseness is an early symptom, 
produced by catarrh or by ulceration. Complete loss of tone may re- 
sult from destruction of the cords. More or less cough, often husky 
and stridulous in character, is present in most cases. Difficulty in 
swallowing occurs when there is much ulceration of the epiglottis and 
of the aryteno-epiglottidean folds. 

The actual condition of .the parts is ascertained by laryngoscopic 
examination. The condylomata appear on the vocal cords, on the 
aryteno-epiglottidean folds, and on the posterior wall of the larynx, as 
a flat, wart-like papule, covered with a grayish pellicle. The mucous 
membrane around it is hypersemic and catarrhal. Gummata are de- 
posits in the membrane, in size from a pin-head to a pea, and situated 
on the true and false vocal cords, on the epiglottis, and elsewhere. 
These syphilitic new formations soon ulcerate. The depth and extent 



SYPHILIS OF THE LARYNX. 



487 



of the ulcerations depend on the stage of the disease, for the syphilitic 
deposits lie the deeper the more chronic the duration of the constitu- 
tional state. The superficial lesions will heal without deformity, but, 
when gummata ulcerate, the destruction is so great that the most seri- 
ous changes ensue in the form and structure of the organ. 

Syphilitic ulcerations extend from the pharynx into the larynx by 
contiguity of tissue. Infiltration of the margins of the epiglottis are 
followed by ulceration and necrosis ; then the aryteno-epiglottic folds 
are invaded, and ultimately the vocal cords are reached and destroyed. 
Extensive deformity may result in such cases from the contraction of 
the cicatrices, and the functions remain impaired permanently. 

Course, Duration, and Termination. — The progress of the ulcera- 
tion in these cases is much affected by the constitutional state, and 
by the treatment. If permitted to pursue its own course in a consti- 
tution depraved by excesses, and by repeated mercurialization, the de- 
struction will be very great. Even extensive ulcerations are, however, 
remarkably restored by suitable medication. As respects the course, 
duration, and termination, everything depends on timely and appro- 
priate treatment. When syphilitic perichondritis of the laryngeal car- 
tilages takes place, the duration of the disease is increased, and its 
importance enhanced in every respect. A fatal termination mr.y occur 
in these cases by oedema of the glottis or by haemorrhage. The ques- 
tion of the relief to be expected by treatment is much influenced by 
the condition of the subject and by the amount of mercury previously 
taken. 

Diagnosis. — There is no well-marked distinction between tubercu- 
lar and syphilitic ulcerations, as respects the appearances seen on 
laryngoscopic inspection. The previous history and attendant cir- 
cumstances possess a high degree of diagnostic importance. In the 
case of tubercular ulcerations the signs of phthisis accompany the 
laryngeal symptoms ; in syphilitic diseases, mucous patches, cutaneous 
affections, nodes, etc., are present, or have appeared at some time since 
a chancre formed. 

Treatment. — Syphiloma of the larynx proceeding to ulceration re- 
quires the most energetic handling to prevent irremediable damage* 
If a proper mercurial course has not previously been administered, it 
should be undertaken at once. The internal use should be conjoined 
with inunction of mercurial ointment and the local application of 
mercurial fumigation. If the deposits are gummata, no treatment is 
so efiicacious as the rapid administration of iodide of potassium — from 
twenty to sixty grains being given every four hours, according to the 
urgency of the symptoms. When destruction of the vocal cords is 
threatened, no time should be lost by the exhibition of small doses. 
For the cases of secondary or tertiary disease, with superficial ulcers, 
sluggish in character, medium doses of corrosive chloride of mercury 



488 



DISEASES OF THE RESPIRATORY ORGANS. 



may be given with advantage. The vapor of iodine can be inhaled 
with good effects, and the tincture painted over the larynx is service- 
able. Various conbinations of iodine and mercury are prescribed in 
chronic syphilis, but, generally speaking, it is better to give these 
agents separately. In broken constitutions stillingia has good effects. 
Cod-liver oil is always useful when the nutrition is poor. 

PERICHONDRITIS OP THE LARYNX. 

Definition. — The cartilages of the larynx are occasionally affected 
by contiguity of tissue, the disease extending from the overlying 
mucous membrane. Perichondritis means an inflammation of the in- 
vesting tunic, the perichondrium. There occur several forms — for 
example: Perichondritis arytoenoidea ; P. cricoidea ; and P. thy- 
roidea. 

Pathogeny and Symptoms. — Inflammation of the laryngeal carti- 
lages may be primary or secondary. Injuries and excessive exertion of 
the voice seem to be causative. The disease usually arises by the ex- 
tension of tubercular or syphilitic ulcers to the perichondrium. In- 
flammation of the perichondrium is followed by softening and disinte- 
gration, or necrosis of the cartilage, swelling and stenosis of the larynx, 
the formation of an abscess, swelling of the neighboring lymphat- 
ics, the discharge of pus internally or externally, or in both directions, 
the formation of fistulae, the separation of the necrosed cartilage, etc. 
There are special symptoms, determined by the particular cartilage 
affected, and general symptoms common to them all. The latter con- 
sist in cough, alteration of voice, or a toneless voice, enlarging lym- 
phatics, and swelling of the, larynx externally, but especially the 
symptoms of laryngeal stenosis, difficult breathing, suffocative attacks 
in paroxysms, a suppressed or stridulous cough, aphonia, etc. By a 
laryngoscopic examination, the seat of swelling may be ascertained^ 
and the position and behavior of the vocal cords will indicate impli- 
cation of the arytenoid and also of the cricoid. Perichondritis thy- 
roidea may be internal or external. A case of the latter has happened 
under my observation in which a fistulous opening existed on the 
front of the trachea. A spot of necrosis probably had formed on the 
anterior plate of the cartilage. A fistulous communication may exist 
between the interior and exterior of the larynx, caused by an abscess 
breaking in both directions. 

Treatment. — The prompt opening of abscesses and laryngotomy 
are very necessary measures when suffocation is imminent. In the 
very rare idiopathic form, recovery may ensue, even after the necrosis 
and removal of a cartilage, but, in the tuberculous cases, death is the 
usual result. 



TUMORS OF THE LARYNX. 



489 



TUMORS OF THE LARYNS. 

Forms. — Tumors of the larynx may be divided into tlie two great 
classes of benign and malignant. In tlie former are grouped papil- 
loma^ the most common form of tumor, having its seat in the larynx ; 
fibroma^ next in frequency, also known as fibrous polypi ; cysts, or 
mucous polypi ; myxoma and lipoma, which are very infrequent. In 
the malignant form is carcinoma, which is comparatively common 
and is usually primary — that is, begins in the larynx. 

Causes. — Tumors occur in the larynx, in the great majority of 
cases, at the most vigorous period in life — from twenty to fifty. Car- 
cinoma is a disease of advanced life, and develops from forty to sixty. 
Some tumors may appear early ; for example, papilloma, which is 
found in children under twelve, but is more frequent at a later period. 
Men are much more liable than women, for in them disease of the 
larynx is invited by their avocations, by speaking and singing in the 
open air, by the irritation of cigarette-smoking, and by the inhalation 
of irritating dust, gases, etc. Carcinoma arises under circumstances 
with which we are unacquainted, unless heredity may be traced. 

Pathological Anatomy. — Papilloma, a tumor of villous structure, 
develops from the vocal cords, epiglottis, and arji;eno-epiglottic folds, 
but its favorite seat is the anterior portion of the vocal cord. It 
consists of branched connective-tissue bodies, containing numerous 
and large capillaries, and are covered by epithelium (\Yagner), 
" The extensive papillomata that occasionally occur in the larynx 
in children are perhaps always of syphilitic origin " (Billroth). As 
seen by the laryngeal mirror, they are branched, cauliflower-like vege- 
tations, which, to a greater or less extent, occupy the upper and mid- 
dle laryngeal cavity. 

Fibroma is a roundish tumor, dirty-white or red in color, and 
usually grows from a vocal cord. It is connected to the point of 
origin by a pedicle of greater or less length, and may have a consider- 
able range of movement. It consists of connective-tissue fibers vari- 
ously interlaced, is somewhat nodulated, abundantly supplied with 
vessels, but contains a small amount of fluid (Billroth, AYagner). It 
grows very slowly, and ultimately attains to great size. 

Mucous cysts belong to the class of retention cysts. A duct of a 
follicle obstructed, the contents accumulate, and thus a tumor is 
formed, attached usually by a broad base, but ultimately becoming 
pedunculated. They grow in the ventricle of Morgagni, and at length 
project into the upper laryngeal cavity (Yirchow).* 

Of the carcinoma attacking the larynx, the epithelial greatly pre- 
ponderates over the other varieties. According to Yon Ziemssen, of 
sixty-eight cases of carcinoma, fifty-seven were of the epithelial 
* " Die krankhaften Gescliwiilste," Band i, p. 246. 



490 



DISEASES OF THE RESPIRATORY ORGANS. 



variety, nine encephaloid and scirrhus, and two villous. The disease 
first appears on the vocal cords and then extends upward to the aryt- 
eno-epiglottic folds. It occurs about equally on the two sides, and 
involves both ultimately. 

Symptoms, Course, and Termination. — In the case of papilloma and 
fibroma of the larynx, the main symptom is that of a gradually in- 
creasing obstruction of the organ — an inspiratory dyspnoea, while ex- 
piration is easy. When the obstruction is considerable, inspiration is 
whistling, noisy, crowing, wheezing, there is constant feeling of a 
need of air, and the lips are rather bluish, the eyes prominent and 
injected. The earliest symptom is an alteration of the voice. Before 
the patient experiences any difficulty of inspiration, the voice has be- 
come raucous, hoarse, and finally toneless. There is also some cough, 
and this becomes husky and stridulous, and violent attacks of inspira- 
tory dyspnoea occur with every paroxysm. A sensation of the pres- 
ence of a foreign body, stuck fast in the throat, comes on as the neo- 
plasm develops. In the further progress of the cases the dyspnoea in- 
creases, swallowing becomes more and more difiicult, the nutrition 
suffers, and the strength declines. Unless relieved by operative pro- 
cedures or, in the case of syphilitic papillomata, by iodide of potas- 
sium, the distress increases with the growth of the tumor, and a slow 
death is caused, accompanied by the horrors of a gradual suffocation. 

Carcinoma of the larynx differs from this disease in other situa- 
tions, by reason of the existence of a distinct prodromal symptom. 
Hoarseness precedes tlie development of the other symptoms by sev- 
eral years, and there appears to be a prodromal hoarseness lasting a 
year or more. Pain is also an early symptom, but this indicates the 
formal development of the local morbid process. The pain is situated 
deeply in the larynx, and is sometimes felt very acutely in the ear. A 
gradual decline in strength and weight, an earthy hue of the complex- 
ion, pearly sclerotics, a weak pulse, and breathlessness on slight exer- 
tion, are significant symptoms indicating the development of the can- 
cerous cachexia. The cervical lymphatics begin to enlarge about six 
months after there are symptoms distinctive of laryngeal disease. 
The larynx usually enlarges somewhat and is tender to pressure. 
When perichondritis occurs, extensive suppuration and oedema greatly 
add to the dimensions of the larynx, as they increase the difiiculty in 
breathing. Some time after the hoarseness, but not long after pain has 
begun, the symptoms of laryngeal stenosis occur. At first the dysp- 
noea is excited only by exercise, but after a time becomes constant and 
most distressing. Cough comes on with the first change in the larynx, 
arfd after a time bloody mucus and, in some cases, considerable blood 
are brought up. Violent paroxysms of dyspnoea occur with the 
cough, with the inspiratory efforts especially. The cough becomes 
husky and stridulous with the progress of the changes in the vocal 



TUMORS OF THE LARYNX. 



491 



cords. Pain in swallowing occurs soon after the disease manifests 
itself in the larynx, especially when the epiglottis and the aryteno- 
epiglottic folds are attacked. Considerable destruction of the parts 
about the entrance of the larynx entails great suffering in attempts to 
swallow, and, the entrance to the glottis not being properly protected, 
particles of food and drink drop into the larynx, exciting violent par- 
oxysms of coughing and dyspnoea. 

The usual duration of carcinoma of the larynx is about two years. 
Cases have terminated earlier, and others have lasted from five to ten 
years, but these are exceptional. Removal of the larynx has pro- 
longed life, but the ultimate termination is in death. 

Diagnosis. — The differentiation, between the several forms of be- 
nign tumors is arrived at by the laryngoscope, so far as the naked-eye 
appearances will solve the question. To distinguish between carci- 
noma and the benign growths, attention must be given to the follow- 
ing points : the age of the subject, the appearance of a tumor after a 
long period of hoarseness, the occurrence of rather severe pain in the 
larynx and in the ear, the enlargement of the cervical lymphatics, and 
the gradual development of the cancerous cachexia — such are symj)- 
toms of carcinoma of the larynx, and to these must be added the ordi- 
nary signs of a tumor. To differentiate between carcinoma and syphi- 
loma, the history of the case becomes essential, for there are no means 
of separating ulcerating gummata from epithelioma on inspection by 
the unassisted eye. The administration of some large doses of iodide 
of potassium will, by the results which follow, illuminate the character 
of the case. This remedy, or its therapeutical congener, mercury, will 
be necessary to separate syphilitic papillomata from the simple form. 

Treatment. — As Billroth finds that papilloma occurring in children 
is apt to be syphilitic, and as the differentiation of certain ulcerations 
of the larynx also require it, large doses of iodide of potassium, or 
suitable mercurial remedies, should be administered at the outset. 
This failing, removal of the neoplasm becomes necessary. There are 
two methods — endo-laryngeal extirpation, and removal by laryngo- 
tracheotomy. After a course of manipulation, which has for its object 
the removal of the sensitiveness of the larynx and fauces, the growth is 
removed by the application of caustics (chromic acid), by the cutting- 
forceps, guillotine, wire ecraseur, etc., or by the galvanic loup, or cautery. 

SPASM OF THE GLOTTIS— PSEUDO-CROUP— LARYNGISMUS 

STRIDULUS. 

Definition. — Sj?as7n of the glottis is a term applied to spasm of the 
muscles of the larynx, innervated by the recurrent or inferior laryngeal 
nerves. The mechanism consists in an irritation of the terminal fila- 
ments of the pneumogastric in the mucous membrane of the larynx, 



492 



DISEASES OF THE RESPIRATORY ORGANS. 



the transmission of this irritation to the pneumogastric nucleus, and 
its reflection over the motor nerves supplying the laryngeal muscles. 

Symptoms and Pathogeny. — Spasm of the glottis is never the initial 
symptom. For the first day or two, the child suffers from a simple 
acute catarrh. There may be slight feverishness, but not high fever; 
there is more or less nasal catarrh ; the eyes are apt to be injected; 
the throat is redder than normal ; the voice is a little hoarse, and there 
is some cough — in fact, the symptoms are those of an acute cold. 
Toward evening the voice may get hoarser, and the cough assume a 
more ringing tone. But in the night the child awakes rather suddenly, 
coughing in the brassy, metallic, resonant tone which is called " croupy." 
Every strong inspiration is accompanied by a loud, crowing stridor, 
and on crying each inspiration has the same character, the expirations 
being wheezy and somewhat stridulous. This peculiarity of the inspi- 
ration is due to sudden and high tension of the vocal cords, they being 
approximated, and consequently narrowing the chink through which 
the air passes. So difficult is the entrance of air, that the accessory 
muscles of respiration are brought into use, the alse of the nose work 
convulsively, the face and lips are somewhat bluish, the countenance is 
anxious, and the inferior portion of the chest is drawn in instead of 
being expanded during inspiration. Such is an ordinary case of pseudo- 
croup. Undoubtedly, there are examples of the disease in which the 
point of irritation is the stomach. An indigestible supper, or some 
improper article eaten during the evening, may set up an irritation of 
the end-organs of the pneumogastric, which may be reflected over the 
laryngeal motor nerves, producing the symptoms of laryngismus strid- 
ulus. In which mode soever produced, spasm of the glottis quickly 
subsides under appropriate treatment, and in an hour or two after be- 
ing awakened by the oppression the child is usually sufficiently relieved 
to become drowsy, barking in its sleep, occasionally, until the morning. 
This experience may be repeated on the following night, and indeed 
for several nights. When this recurrence of the paroxysms takes 
place, the case awakens renewed anxiety, lest an exudation may be 
forming in the larynx. If the paroxysms recur for two nights, there 
will be attacks during the day also. The author has observed a few 
cases in which the spasms continued for several days ; without being 
violent at any time, the cough had always the " croupy " character, 
and a strong inspiration developed stridor. 

Course, Duration, and Termination. — The simplest cases consist of a 
mild acute catarrh, inducing a nocturnal attack of spasm of the glottis, 
which terminates in an hour or two. The catarrh soon subsides, and 
there is no return of the spasm of the glottis until succeeding attacks 
of catarrh renew the disturbance in the nervous apparatus of the larynx. 
As only certain children, though by no means a small proportion, suffer, 
there is probably a peculiar mobility of the nervous system necessary. 



CROUP. 



493 



As the mobility of the nervous system is much more pronounced in 
children than in adults, we have in this an explanation of the fact that 
spasm of the glottis is a disease of early life, and rarely occurs after 
twelve. Although a malady of little importance, spasm of the glottis 
accompanies some of the most serious diseases. Thus it occurs during 
the course of true croup, diphtheria, oedema of the glottis, etc., and may 
be the immediate cause of death ; and in all cases adds materially to 
the difficulties, by the frequent spasms in the laryngeal muscles. As 
it usually occurs in children, arising in a reflex disturbance, having its 
origin in an acute catarrh, or an acute indigestion, it always ends in 
recovery. There are occasional (rather rarie) cases in which the catarrh 
terminates in oedema of the glottis. 

Diagnosis. — The manner of its occurrence and the promptness of 
the cure sufficiently indicate the nature of pseudo-croup without the 
laryngeal mirror. 

Treatment. — Formerly, every case of the disease was subjected to 
a severe ordeal, and, when bloodletting and tartar emetic were aban- 
doned, emesis was still persevered in. ISTo perturbating agents of this 
kind are really necessary. A few di'ops of the fluid extract of ipecac, 
given every twenty minutes until nausea is produced, will relieve if a 
cold wet pack about the neck has failed. From five to twenty grains 
of the bromide of potassium will usually succeed, and will be more ef- 
fective if some chloral is added. From ten minims to 3 j of paregoric 
often arrests the paroxysms. A minute dose of pilocarpine nitrate or 
muriate (^^ to ^ grain) will stop the spasms usually when diaphoresis 
begins. As it is so mild a disease, the simplest means will suffice to 
cure an attack. Children accustomed to the attacks should receive 
prophylactic treatment. A daily morning cold bath to diminish the sus- 
ceptibility to colds, the sirup of the iodide of iron, or the lactophos- 
phate of lime, to promote the body nutrition, suitable clothing, and out- 
door occupation, are the most approved means to prevent a recurrence 
of the seizures. 

CROUPOUS LARYNGITIS— TRUE CROUP. 

Definition. — The preponderance of authority is in favor of that 
view that the so-called membranous croup is only laryngeal diphtheria. 
The author is one of those who maintain that croupous laryngitis^ or 
membranous croup, is an independent, substantive disease ; that we 
have a croupous laryngitis as we have a croupous bronchitis and a 
croupous enteritis. The author believes that this disease is distinct 
and separate from diphtheria, for the following reasons : it occupies 
the larynx exclusively, is a purely local alfection, the exudation is on 
and not in the mucous membrane, and that systemic poisoning, or sec- 
ondary septicaemic and infective embolic processes never result from it. 

Causes. — Croup is a disease of childhood, and very rarely occurs 



494 



DISEASES OF THE RESPIRATOKY ORGANS. 



later than tlie second dentition, and attacks male children by prefer- 
ence, in the proportion of three to two. It is not merely the ill-fed 
children of the poor, or the inheritors of scrofula and rickets, who are 
chiefly attacked, but the vigorous and well-nourished are more liable. 
It is certain that heredity has an important influence in its causation, 
in that certain families are especially liable to destructive visitations, 
and others, living under similar conditions, escape. Notwithstanding 
the prevalent opinion that humidity, coldness, and variability of cli- 
mate favor the development and spread of croup, we find that Lombard 
says " he has sought in vain to discover any difference in the develop- 
ment of this disease as regards climate, latitude, and altitude." * It 
seems, nevertheless, well established, that humidity favors its occur- 
rence, and that more cases occur in winter and spring than in summer. 
That true croup prevails as an epidemic is highly improbable, but, as 
diphtheria does, the error, if it exist, has arisen by confounding the 
diseases. A croupous laryngitis sometimes arises during the course of 
the acute infectious diseases, as measles, scarlatina, small-pox, etc., but 
of measles especially. This may be a diphtheritic process superadded 
to an existing lesion, but is more probably a mere croupous inflamma- 
tion. 

Pathological Anatomy. — The initial hypersemia is of an intense 
character ; the mucous membrane is swollen, has a deep-red color, is 
marked by an exceedingly fine but diffused arborescent injection, and 
here and there by minute ecchymoses, and the sub-mucous connective 
tissue is more or less (edematous. In the progress of the case the red- 
ness subsides to a large extent, but the membrane continues somewhat 
thickened for some time longer. Soon after the hyperaemia attains its 
maximum, there appears on the surface of the inflamed mucous mem- 
brane a grayish, semi-transparent pellicle, which soon becomes thicker, 
grayish-white, yellowish, or brownish — an opaque false membrane. At 
various places the false membrane differs in coherence, density, and 
adhesiveness : here, several lines in thickness, uniform in structure, and 
firmly attached to the mucosa ; there, in flakes or patches, loosely at- 
tached to the surface beneath. The false membrane is found on the 
vocal cords throughout their whole extent usually, spread over the ven- 
tricles, and attached to the inner surface of the epiglottis. There may 
be none found post mortem, it is alleged ; but probably in these ex- 
amples there was an error of diagnosis. Successive deposits — two or 
three — may occur ; the first exuded is softened by the serum which 
transudes, as does the albumen, and is mechanically detached in the act 
of coughing. As expectorated it usually appears in the form of grayish- 
white shreds or casts, several lines in thickness, and tolerably tough. 
Sometimes a cast of the trachea and tubes of considerable extent is 



* "Traite de Climatologie Medicale," etc., tome iv, Paris, 1880, p. 401. 



CROUP. 



495 



thrown off, but this is exceptional. On microscopic examination, the 
false membrane is found to be composed of a fine network of fibrillse, 
holding in their interstices leucocytes, and chemically of an albumi- 
nous nature, or of fibrin. Soon after the false membrane forms on the 
epithelial surface of the mucosa, a process of detachment begins, by 
the accumulation of serum, having suspended in it muco-pus, cast-off 
epithelial cells, blood-corpuscles, etc. The mucous membrane, when the 
exudation is detached, is found to be unaffected, except the hyper^emia, 
and the imbibition of fluid affecting the epithelial cells. In this ab- 
sence of direct implication of the epithelium lies the distinction be- 
tween croup and diphtheria, for in the latter the false membrane is 
closely united to, and is probably developed from, the cells of the epi- 
thelium, as E. Wagner has apparently shown. After the exfoliation 
of the first croupous exudation, there may be several successive crops 
of exudation, or, ceasing to form again, a cure is effected. The false 
membrane is not confined to the parts on which it first appears, but 
extends upward into the pharynx, but especially downward into the 
trachea, primary bronchi, and smaller bronchi. As the membrane ex- 
tends toward the finer tubes, it becomes less fibrillary and more cellular, 
until at length it is a mere muco-purulent fluid. The lungs are affected 
by emphysema, and here and there atelectasis, the result of the inspir- 
atory obstruction and the tenacity of the exudation blocking some of 
the finer tubes. 

Symptoms. — The attack of croup usually but not invariably begins 
as an acute catarrh of the larynx ; there is a feeling of heat and irrita- 
tion in the organ, and the voice is a little husky ; there is cough with 
something of stridor about it, and fever, restlessness, thirst, anorexia, 
and disturbed sleep, accompany the evidences of laryngeal mischief. 
When the fauces are inspected, more or less redness, sometimes dusky 
redness, will be observed, and also small patches of a thin, pellicular 
exudation of a grayish-yellow color, studded over the palate, tonsils, 
and pharynx. These patches presently coalesce and then form a 
denser membrane several lines in thickness, of a yellowish-gray or ash 
color. As huskiness of voice was one of the initial symptoms, the 
same patches of pellicular exudation are forming in the larynx. Al- 
though it is aflSrmed of croup that the exudation spreads sometimes 
over the tongue, cheeks, lips, into the nose, ears, etc., these cases so 
behaving are examples of diphtheria, it is most probable, for true croup 
does not extend beyond the pharynx and soft palate. The submaxil- 
lary glands become somewhat tumid and swollen, but not the chain 
of cervical glands extending under the sterno-cleido-mastoid muscles, 
which are enlarged in diphtheria. Usually from one to two days are 
occupied with the development of the catarrhal form, but other and 
rare cases commence with abruptness in the night, as an ordinary 
spasm of the glottis. In what mode soever developed, there now 



496 



DISEASES OF THE RESPIRATORY ORGANS. 



appear the symptoms of laryngeal obstruction. The hoarseness has 
become fixed, and the cough assumes a clanging, metallic, or "croupy " 
character, rapidly changing to a stridulous, husky, and toneless sound. 
Now and then, on sudden, deep inspiration, there is still the peculiar 
whoop, but the voice becomes more and more husky. Dyspnoea now 
comes on. The respirations increase in frequency, and are seen to 
be so labored as to require the aid of all the muscles. The child 
can not lie down. If, exhausted by the efforts made, the child seeks 
repose, resting its head high upon a pillow, it soon starts up in a 
fright, breathing more heavily, and with a shrill, whistling inspira 
tion. Tossing from side to side, he seeks, in endless changes of po- 
sition, for the relief which no change brings. With open mouth, 
rapidly working aXsQ of the nose, and every respiratory muscle called 
into play, he exerts himself to the utmost to obtain the necessary air, 
but ineffectually, the lower portion of the chest being drawn in deeply 
with each inspiration. The air passes with difficulty through the nar- 
rowed chink of the glottis, and hence the slowness, and the whistling, 
crowing, and stridulous inspirations, which can be heard at quite a 
distance from the patient. Ultimately the narrowing of the glottis is 
such that expiration becomes difficult and somewhat noisy. To the 
difficulty of breathing from the swelling of the mucosa and the pres- 
ence of the false membrane are now added paroxysmal attacks of spasm 
of the glottis. When these attacks come on, suffocation seems immi- 
nent. The child, who has been restless when these seizures are felt, 
tosses wildly about with an agonized expression, tears at his throat to 
remove some obstacle, the face cyanosed, the al^e of the nose widely 
separated, the inspiratory efforts gasping, and the muscles working to 
their utmost, the body covered with a profuse sweat from the inten- 
sity of the exertions ; and at last, when death seems at hand, a little air 
enters the chest, the breathing becomes somewhat easier, and the child, 
exhausted and stupefied by the carbonic acid which is accumulating, 
drops into a fitful sleep of a few minutes' duration. These suffocative 
attacks appear at shorter intervals. By some these attacks are sup- 
posed to be due to a paresis of the laryngeal muscles instead of spasm, 
and Steiner supports the opinions of Niemeyer on this point. In some 
cases there occur decided remissions between the attacks of suffocative 
dyspnoea. Considerable portions of false membrane being expelled, 
air again enters the lungs ; the cyanosis disappears, the fever ceases, 
and some refreshing sleep is obtained. As the false membrane is 
renewed again, the former difficulties are resumed ; the breathing be- 
comes difficult, and the suffocative attacks even more violent. Some- 
times a mass of exudation is suddenly detached and thrown against 
the under surface of the vocal cords ; breathing is suspended, the child 
turns deeply blue in the face, and violent coughing sets in, detaching 
the mass, and either carrying it down by inspiration, or outward by an 



CROUP. 



497 



explosive cough. In the cases which tend to a favorable termination, 
the appearances of improvement, noted between the suffocative at- 
tacks, are maintained. The paroxysms of suffocation become less 
frequent, and the constant dyspnoea visibly lessens ; the cough has less 
and less of the barking character, and the expectoration is more abun- 
dant and looser ; the fever disappears ; the voice gradually passes from 
toneless to husky and loud ; sneezing occurs, and the nose discharges. 
If, instead of improvement, the case goes on as usual to a fatal ter- 
mination, the final stage of asphyxia^ or carbonic-acid poisoning, is 
now entered on. The cyanosis deepens, the agonized expression of 
countenance is replaced by indifference, drowsiness, and stupor, the 
eye grows dull and is nearly closed, the difficulty of breathing con- 
tinues, and the respirations are frequent and shallow, but without the 
whistling and stridor. Kow and then a paroxysm of dyspnoea comes 
on, in which the child is roused from its somnolent condition, gasps 
for breath, struggles, and then lies down, passing at once into an 
apathetic state. The symptoms of vital failure now come on : the 
pulse becomes rapid and weak ; a cold, clammy sweat covers tho 
body ; the extremities are cold, the somnolence deepens into stupor 
and insensibility, carpopedal contractions occur, and sometimes gen- 
eral convulsions. 

Course, Duration, and Termination. — The first stage, characterized 
by the symptoms of laryngeal catarrh, runs its course in twenty-four 
to thirty-six hours. The fulminant cases, beginning abruptly at the 
second stage, with its symptoms of laryngeal stenosis, will terminate 
fatally within two days, and sometimes within one day. The usual 
duration of ordinary cases is about one week, and rarely do cases ex- 
tend to ten days. The second stage may continue from one to four- 
teen days, but the latter duration must be regarded as exceptional. 
The third — the stage of asphyxia — lasts from thirty-six to forty-eight 
hours. In most of the cases the cause of death is general paralysis, 
due to carbonic-acid poisoning. Yery rarely is death caused by ap- 
noea, the access of air prevented by closure of the glottis with shreds 
of false membrane, or by spasm. CEdema of the glottis, croupous 
pneumonia, oedema of the lungs, or capillary bronchitis, may be a 
cause of death. 

Diagnosis. — Until the characteristic membranous formation appears 
in the throat, croupous laryngitis may be confounded with pseudo- 
croup or laryngismus stridulus. The latter occurs frequently in some 
children, comes on suddenly in the night, and after a few hours ceases 
to give trouble. True croup develops more slowly and does not pre- 
sent the apparent laryngeal obstruction of false croup until the case is 
well advanced. The fulminant form, it is true, begins abruptly and 
with violence, but there is no amelioration in the condition as in pseudo- 
croup. The most certain means of diagnosis consists in the discovery 
34 



498 



DISEASES OF THE RESPIRATORY ORGANS. 



of the exudation, whicb soon appears after the initial symptoms are 
well declared. 

Treatment. — The means employed in the treatment of membran- 
ous laryngitis are naturally divisible into two classes — local, systemic. 
An almost infinite variety of remedies have been applied to the throat : 
we mention those that are really useful. Caustic applications, as ni- 
trate of silver, the mineral acids, etc., are injurious ; for, although they 
may remove the existing membrane, they can not prevent its reforma- 
tion, and the extension of the exudation is invited to the healthy tissue 
corroded by the caustic. Solvents that are not irritating are most use- 
ful. The first and most important one is lime-water, which may be 
applied by a large soft probang, or atomized by a spray douche. The 
application of the spray should be nearly continuous ; of the probang, 
frequent. An excellent method consists in slaking bits of freshly 
burned lime in water placed in a wide-mouthed bottle — the patient 
inhaling the vapor as it arises. Next to lime-water is lactic acid, as a 
solvent, and it is as safe as it is efficient. Sufficient of the acid should 
be added to water until a distinctly sour solution is obtained, and this 
may be freely applied by the spray douche or probang. Recent re- 
ports are very favorable to washed sulphur or sublimed sulphur freely 
dusted over the affected parts in diphtheria. Chlorate of potassa is 
preferred by many, either atomized or on probang or brush ; it is also 
used with chloride-of-iron tincture, or the latter, undiluted, is applied 
on a camel's-hair brush to the false membrane and fauces. The bro- 
mides of potassium and ammonium, in solution, are also sprayed over 
the throat and fauces. Good results have been claimed for a mixture 
of fluid extract of belladonna and the bromides in solution, used in the 
same way, a continuous application of the spray for hours at a time, 
or until the pupils are affected. It is claimed for this mixture that the 
belladonna allays the spasms of the glottis. A solution of chloral has 
been employed as a local application, both for its antiseptic effects and 
as a moderator of the reflex spasms of the laryngeal muscles. The air 
of the apartment should be kept moist with the vapor of water, or 
impregnated with the vapors of eucalyptus and turpentine oils, which 
can be accomplished by boiling in a suitable vessel some eucalyptus 
leaves with turpentine. This expedient has been found to be exceed- 
ingly useful in the Children's Hospital at Lisle.* The internal reme-! 
dies are equally numerous. There are three main objects to be kept" 
in view in the treatment of true croup : to detach, remove, and pre- 
vent the formation of the false membrane ; to prevent the attacks of 
laryngeal spasms ; to maintain the strength. Quinine, calomel, chlorate 
of potassa, tincture of iron, and the bromides, are recommended, and 
some of them much lauded by their respective proposers. There are 



* " Journal de Therapeutique," February, 1886. 



CORYZA. 



499 



two of unquestionable utility — quinine and bromide of ammonium. 
Quinine should be administered in full doses (for a child, three to five 
grains every three or four hours). Cinchonism should be kept up as 
fully as possible, with the object to stop the fibrinous exudation. In 
alternation with quinine, or by itself, should be administered full doses 
of bromide of ammonium. The particular fact which gives value 
to this and the other bromides is its elimination by the bronchial and 
faucial mucous membrane, thus acting locally. Furthermore, quinine 
and the bromides check the spasm of the laryngeal muscles, a most 
important action. The mechanical effect of an active emetic is often 
necessary to dislodge the obstructing membrane. Apomorphine is 
especially effective for this purpose. Ipecac is too depressing, tartar 
emetic is highly objectionable ; alum and subsulphate of mercury are 
the best. According to Barker, of New York, the subsulphate has 
special power as a remedy for croup, an opinion in which the author 
is disposed to share. It should be given early, and not wait for severe 
obstruction. Besides the agents above advised — quinine and the bro- 
mides — for the laryngeal spasms chloral is to be commended. The 
author has preferred to give chloral and bromide of ammonium to- 
gether, and the quinine separately. Besides its power to allay the 
spasms, chloral is one of the few remedies which possess the property 
to check the formation of an exudation. Many practitioners hold that 
chlorate of potassa has this property (Steiner), and this remedy is 
probably more largely prescribed than any other in croup and diph- 
theria. There are practitioners who still hold to the aplastic virtues 
of calomel, and use this remedy in large doses, with asserted success, 
but the most approved authorities are opposed to both opinion and 
practice (Oppolzer, Steiner). The measures to maintain the strength 
are very important. Alcoholic stimulants possess, according to the 
Brooklyn physicians, some peculiar, possibly specific curative power. 
It is alleged that the best results are obtained in diphtheria by large 
and sustained administration of whisky, brandy, etc. How far these 
facts are applicable to true croup remains to be determined. 



CORYZA— NASAL CATARRH. 

Definition. — By the term coryza is meant a catarrhal inflammation 
of the nasal mucous membrane. It may be either acute or chronic. 

Causes. — Atmospherical causes are the most frequent and influ- 
ential. The exposure of the neck to a current of cold air, of the 
feet and ankles to cold and dampness, passing from a warm to a 
cold atmosphere, and from a cold to a warm atmosphere suddenly, 
are among the most usual causes. Irritating gases and vapors, the 
spores of some plants, certain powders, as ipecac, tobacco, etc., excite 
an irritation of the nasal mucous membrane. Heredity is an occa- 



500 



DISEASES OF THE EESPIRATORY ORGANS. 



sional factor. Epidemic influence now and then prevails on an exten- 
sive scale. 

Pathological Anatomy. — An intense hyperssmia is the first change, 
with an arrest of secretion. This is soon followed by swelling or 
tumefaction of the membrane ; the epithelium is detached, and a great 
number of new cells are produced. The raucous glands furnish an 
abundant secretion very rich in saline constituents. If the congestion 
is intense, vessels are ruptured, and more or less epistaxis results. 
With the progress of the case, a change occurs in the character of the 
discharge ; at first watery and transparent, it becomes thicker and 
opaque with the increase of the pus-cells (leucocytes). When recovery 
takes place, the secretion diminishes, the congestion subsides, and the 
swelling of the membrane disappears. Such is the usual course of an 
acute inflammation. In the chronic form, the mucous membrane is 
reddish-brown, in very old cases grayish, the veins are dilated and 
varicose, often forming polypoid protrusions. There may be more or 
less extensive ulceration, and losses of substance, in old cases. The 
discharge is thick, greenish , and often offensive from decomposition. 
Large collections of inspissated mucus form on the turbinated bones. 

Symptoms. — Taking cold in the head is announced by chilliness, 
weariness, headache, and general muscular soreness. The nares are 
dry, feel stuffed and uncomfortable, and an inclination to sneeze is 
often felt. Presently the nose pours out an abundant watery and 
saline discharge, the anterior nares are red and inflamed, and sneez- 
ing is frequent. The discharge soon assumes a purulent character, 
and contains numerous micrococci. The voice has a peculiar tone, 
rather nasal and muffled from the swelling of the nasal mucous mem- 
brane. In a few days the swelling subsides, the secretion lessens, and 
health is restored in about two weeks from the beginning of the attack. 
The chronic form may grow immediately out of the acute affection, or 
it may be the result of repeated acute attacks, or develop from the con- 
tinued operation of the causes. In the chronic form of the disease, the 
mucous membrane is either livid, the vessels varicose, and the connec- 
tive-tissue basis of the mucous membrane hypertrophied, or the mem- 
brane is pale, thin, bloodless, and atrophied. The discharge consists 
of greenish, offensive pus, or of scales taking the form of casts of the 
bones, which are also offensive from decomposition. If the mucous 
membrane is destroyed by ulcerations, and caries of the bones has 
occurred, the case is then called ozoena. The morbid process extends 
through the nasal passages and into neighboring cavities. 

Course, Duration, and Termination. — The acute form reaches its 
maximum in a few days, and terminates in from fourteen to sixteen 
days if uninterfered with. The chronic form is excessively obstinate, 
and continues with varying fortunes for several years. During the 
summer and autumn it is milder, but in the winter and spring it 



CORYZA. 



501 



is worse. Although there is no danger to life, the disease in its chronic 
form is difficult to cure. The popular notion that extension to the 
lungs takes place is entirely unfounded. In the phthisical, the coexist- 
ence of nasal catarrh and the pulmonary lesions, which is very common, 
is often supposed to mean the dependence of the latter on the former. 

Treatment. — An existing constitutional dyscrasia, especially syphi- 
lis, needs attention. If the least suspicion may be entertained, an 
iodide-of-potassium course should be carried out. Where there is a 
strumous diathesis, cod-liver oil, the phosphates, iodide of iron, etc., 
should be employed. If we have to deal with an attack of acute ca- 
tarrh, an attempt may be made, and will often prove successful, to abort 
it by the administration of a full dose of quinine and morphine (for an 
adult, gr. XV of quinine and gr. ss. of morphine). When established, 
the best remedy is Lugol's solution, one drop every hour or two. If 
there is fever, one drop of tincture of aconite-root every hour will prove 
efficient. If the secretion is watery and profuse, tincture of belladon- 
na may be given with the aconite, two drops every two hours. In the 
local treatment of chronic catarrh, the first step necessary is to clear 
the mucous surface of adherent discharges. The nasal douche, so much 
employed, has so often given rise to inflammation of the middle ear, 
by forcing the application into the Eustachian tube, that it must be 
used with caution. The post-nasal syringe and tepid water containing 
a little common salt are the best materials for cleansing the passage. 
Numerous are the kinds and forms of applications — gaseous, liquid, 
and solid. The volatile applications consist chiefly of iodine and car- 
bolic acid, separately or in combination. The tincture of iodine and 
carbolic acid may readily be volatilized and inhaled from a small bot- 
tle. Still more generally successful is the introduction of a cocaine 
tablet. Containing -Jth or -|-th grain in the form of a flattened disk, 
the tablet is introduced alongside the septum, where it is allowed to 
dissolve, the head being inclined backward to permit the medicament to 
apply itself to the affected surface. One should be introduced on each 
side of the nares, twice or three times a day. The effect is usually 
prompt and complete. These tablets are the more effective the earlier 
they are applied. The liquid applications consist of solutions of chlo- 
rate of potassa, chloride of ammonium, sulphates of zinc, cadmium, 
and copper, acetate of lead, etc. The solutions must be very dilute, not 
stronger than one grain of sulphate of zinc to four ounces of water, for 
example, because of the very sensitive condition of these parts. When 
there are great thickening and ulceration, requiring strong applica- 
tions, they must be made with the guidance of the mirror, and be con- 
fined to the part diseased. The most effective application, according 
to the author's experience, is a powder composed of tannin and iodo- 
form ( 3 j — gr. x) applied by means of an insufflator. The membrane 
must be first cleansed, then the powder is dusted over the diseased 



502 



DISEASES OF THE RESPIRATOEY ORGANS. 



part, using a very small quantity. Pressure by means of a graduated 
series of bougies is a valuable mode of treating those cases in which 
the membrane is much thickened. 

EPISTAXIS— NASAL HJEMORRHAGE. 

Causes. — The Schneiderian mucous membrane is abundantly sup- 
plied with blood-vessels and bleeds easily. Epistaxis may be caused 
by ulceration of the membrane, by vascular tumors, by traumatism, 
by a constitutional state — the hsemorrhagic diathesis — by irritation of 
the mucous membrane, and by mechanical causes, as valvular disease 
of the heart, and the pressure of an intra-cranial growth, etc. 

Symptoms.— There may be a sense of fullness of the head, head- 
ache, noises in the ears, vertigo, precede the epistaxis, and be relieved 
by it, or the bleeding may occur without any previous symptom to 
indicate its approach. The blood may at first be observed on the 
handkerchief ; a sense of moisture about the nares suggests the neces- 
sity of blowing the nose, and then blood is seen coming drop by drop, 
and from a single nostril. The blood may be discharged by the pos- 
terior nares and be expectorated. On inspection of the fauces, it will 
be seen trickling down the soft palate and uvula, which will prevent 
the mistake of supposing it comes from the lungs. The quantity of 
blood discharged varies greatly. In most cases an ounce or two is lost, 
when the flow spontaneously ceases ; again, many ounces — a pint, a 
quart even — may be lost, completely blanching the patient, and only 
ceasing because of the faintness. If the bleeding occur in a subject 
of the hsemorrhagic diathesis, it may continue to faintness and be re- 
sumed asrain as soon as the circulation reo^ains its force. Under these 
circumstances epistaxis may endanger life. Again, epistaxis may occur 
periodically, as a manifestation of malaria, or take the j)lace, vicariously, 
of the menstrual or hsemorrhoidal flux. Those cases due to the pres- 
sure of a tumor on the cavernous sinus, or pterygoid plexus, are ac- 
companied by swelling of the eyelids, injections of the eyes, retinal 
changes, and the symptoms proper to tumor of the brain. 

Diagnosis. — There can be no difliculty, if the inspection is made 
when the blood is flowing, in determining the source of the haemor- 
rhage. When, however, the bleeding occurs in sleep, from the poste- 
rior nares, and is swallowed, there may be, if vomiting of the blood 
occurs, much difliculty in ascertaining the true source. But the absence 
of any evidence of stomach ulcer and the occasional occurrence of nose- 
bleed will suggest the means of differentiation. The same method of 
analysis will be equally applicable to the apparent expectoration of 
blood, for the absence of pulmonary disease and the occasional occur- 
rence of epistaxis will decide the probability in favor of bleeding at 
the nose. 



THE URINE. 



503 



Treatment.— The application of cold, in the form of ice, small 
pellets of which may be introduced into the nares, while a block of 
ice hollowed out to fit the nose may be put on outside, will often be 
sufficient to arrest the bleeding. Pressure on the artery supplying 
the anterior nares may be easily effected by passing the little finger 
under the lip, near the middle line where the artery may be felt. 
Simply pressing the nares together, to enable the blood to coagu- 
late, may often suffice. If pressure and cold fail, a solution of tan- 
nic acid, or of alum, or of acetate of lead, may be thrown into the 
nares, and, if these fail, a solution of Monsel's salts. The measures 
above advised may be supplemented by the hypodermatic injection 
of ergotin, if necessary, and by the stomachal administration of arte- 
rial sedatives, as veratrum viride and digitalis. All other expedients 
failing, the posterior nares must be plugged. 



DISEASES OF THE KIDNEY. 



THE URINE— ITS COMPOSITION AND PATHOGENIC RELATIONS. 

Organic and Inorganic Constituents.— The urine is a complex fluid 
which represents the waste of certain organic and inorganic constitu- 
ents of the body. Full knowledge of its composition is, therefore, 
necessary to comprehend the metabolism of the tissues. Also, as the 
urine contains the products of the pathological changes occurring in 
the kidney, it is obvious that, to know these processes aright, it is 
imperative to ascertain the variations from its normal composition and 
character. 

A healthy, fully developed adult passes from forty to fifty ounces 
of urine in twenty-four hours. But the quantity must always be con- 
sidered relatively to the quality, or the urinary water must stand in a 
certain ratio to the urinary solids. In round numbers, the quantity of 
solid matter contained in normal urine is about 4 per cent. A sim- 
ple rule for approximately determining the amount of solids in any 
given sample consists in doubling the last two figures of the specific 
gravity. Thus, if the specific gravity be 1,020, by multiplying 20 by 
2, we have 40 — or 40 parts in 1,000, which is 4 per cent. The whole 
amount of urinary solids excreted in twenty-four hours is, hence, 
merely a question of proportion : for example, if 40 parts of solids be 
contained in 1,000 parts of urine, how much in the daily quantity of 
urine discharged in the case under consideration ? 



504 



DISEASES OF THE KIDNEY. 



The solids of the urine consist of organic and inorganic matter. 
The following are the constituents of the organic matter : urea^ uric 
acid, hippiiric acid, hreatinin, traces of phenylic, oxalic, lactic, and 
other acids of the aromatic series, and coloring matters (urobilin or uro- 
hgematin, or urochrom ; uroxanthin or indican). 

The inorganic constituents consist of phosphates (alkaline and 
earthy), sulphates, and chlorides. Minute quantities of unoxidized sul- 
phur and phosphorus are, also, present in normal urine. 

In the examination of urine the following points are to be consid- 
ered : the quantity passed in twenty-four hours relatively to the sol- 
ids contained in it ; the color, clearness or cloudiness ; the odor the 
reaction (acid, alkaline, or neutral) ; the specific gravity ; the presence 
or absence of visible solid matters (uric acid, urates, mucus, blood, etc.). 

The quantity of urine passed in twenty-four hours should be accu- 
rately measured, and a specimen of the whole should be reserved for 
examination. 

In every case, whenever practicable to do so, the morning urine — 
that passed on rising — and the evening urine — that passed several 
hours after the principal meal of the day — should be submitted to ex- 
amination. 

The quantity in the normal individual is from forty to fifty fluid- 
ounces. The color is that of straw, of amber, or is pale yellow. Urine 
should be completely transparent, or at most cloudy only after cooling, 
in consequence of the precipitation of the urates. The reaction of 
urine is acid. The diet may affect this strictly within normal condi- 
tions, as for example under a vegetable diet, exclusively, the reaction 
becomes neutral or even alkaline. The specific gravity ranges from 
1,004 to 1,030, according to the age of the subject, the character of the 
diet, and, especially, the temperature of the air, for when the cutane- 
ous transpiration is abundant, the amount of urinary water is propor- 
tionally lessened. 

The composition of the urine in disease varies in respect to the pro- 
portion of its normal constituents, and by the appearance of new sub- 
stances. Both require some consideration. 

The Organic Constituents — Urea. — Normal urine contains about 
three per cent, of urea, and the average daily excretion of a medium- 
sized adult is somewhat more than one ounce — about five hundred and 
forty grains. The amount present is increased in febrile affections. 
In diseases of the liver, with alteration of its structure and especially 
with considerable loss of the substance of the organ, the quantity of 
urea excreted is considerably less than normal. In cases of albumi- 
nuria, also, the percentage of urea is low, because the secreting struct- 
ure of the kidney is damaged, but it is found in the fluid of dropsy, 
and in other fluids, in considerable quantity, although the amount pro- 
duced is below the normal. 



THE URINE. 



505 



Several processes for the quantitative determination of urea have 
been proposed, but only those capable of ready adaptation to clinical 
purposes need be mentioned here. Heretofore the process of Liebig 
has been most generally employed. This method is based on the fact 
that urea is precipitated by nitrate of mercury from its solution — an 
insoluble compound of mercury and urea being formed. The phos- 
phates, sulphates, and carbonates are first precipitated by means of a 
saturated solution of baryta ; then, on slowly adding the mercuric 
nitrate solution, a compound of this reagent and the urea is thrown 
down. With standardized solutions, the proportion of urea can be 
readily estimated. 

A still more convenient process for ascertaining the quantity of 
urea, at least approximately, is that devised by Dr. Squibb, of Brook- 
lyn. It is known as the " hypochlorite process," and consists in de- 
composing the urea by the official solution of chlorinated soda (XI. S. 
Pharmacopoeia) and collecting the escaping nitrogen, from the quantity 
of which can readily be determined the amount of urea present. Al- 
though not absolutely accurate, this method affords a sufficiently close 
approximation for all practical purposes. Another comparatively con- 
venient method is called the hypobromite," and is, as the Squibb pro- 
cess, based on the decomposition of the urea and collection of the nitro- 
gen. A very simple apparatus for carrying out this method has been 
devised by Dr. W. H. Greene,* of Philadelphia, and a similar arrange- 
ment has since been proposed by Dr. Doremus, f of New York. The 
liquid to effect the decomposition of the urea, and separate the nitro- 
gen, is a solution of bromine in caustic soda. For exact and detailed 
descriptions of these several processes, the reader is referred to the 
recent works treating of the composition and chemistry of the urine. 

Uric Acid and Urates. — The whole amount of uric acid excreted in 
twenty-four hours does not exceed twelve grains, and may be as low 
as five grains, and between these extremes it oscillates in healthy 
adults. It is extremely insoluble in water, and is precipitated as the 
urine cools. The forms assumed by uric acid are so characteristic 
that it is readily recognized on microscopic examination. (See post.) 
In a normal condition uric acid is not found in the blood, but in gout 
it is either produced in excessive amount, or fails to be oxidized into 
urea and thus excreted. The source of uric acid remains obscure. 
The most widely entertained theory regards it as a substance inter- 
mediate between albumin and urea, and when present in quantity sig- 
nifies deficient oxidation. When the urine is highly acid, and concen- 
trated, uric acid is in excess. 

The word urates signifies a cloudiness or sediment composed of 
combinations of uric acid with various bases. The most common are 

*The Philadelphia " Medical Times," January 12, 1884. 
f The " Medical News " (Philadelphia), May 30, 1885. 



506 



DISEASES OF THE KIDNEY. 



the urate of soda, urate of ammonia, and urate of calcium. The least 
abundant is urate of potassium. Even when abundant, the urates are 
usually held in solution at the temperature of the body, to be cast down 
when the urine cools, then forming an abundant milky or chalk-like 
deposit, which may indeed have a brick-dust appearance, especially 
should uric acid be in excess. On heating such urine, the deposit or 
sediment clears up — a reaction which serves to distinguish between 
the urates and albumin, or phosphates, both of which are increased by 
boiling. The appearance of the urates under the microscope is shown 
in Fig. 

Hippuric Acid. — The amount of hippuric acid varies with the diet, 
and certain unknown conditions of the assimilation. From ten to fif- 
teen grains are excreted in the urine of a healthy adult in twenty-four 
hours. It is increased in diabetes, and by the use of such fruits as 
cranberries, blackberries, etc. 

The other acids of the aromatic series have but little clinical sig- 
nificance at present. 

Kreatinin. — The source of kreatinin is kreatin, one of the products 
of retrograde changes in muscular tissue. It is an alkaloidal substance 
of considerable power, but its clinical relations are unknown. The 
amount excreted in twenty-four hours ranges between eight and twenty 
grains, it is supposed. 

Urine Pigments or Coloring Matters. — These have considerable im- 
portance. There are two — urobilin ; indican. The former is derived 
from hcematin, the coloring matter of the blood, by the action of the 
bile acids ; the latter from indole a substance produced in the course of 
the pancreatic digestion of the proteids. Indol, after absorption into 
the blood, is converted into indican, and is thus excreted by the urine. 
Urobilin, or a substance corresponding to it, is variously named by 
different observers. By George Harley it is called urolimmatin ; by 
Heller, iiropliain. It is the most important urine pigment, if not the 
sole coloring matter. The quantity normal to the urine is increased in 
certain diseased states — in liver diseases, in fevers, and in certain dis- 
orders of the vascular system. 

Indican is probably a normal constituent of the urine, but by some 
it is held to be a pathological product. It is Heller's uroxanthin, and 
is supposed to be derived from i7idol, a product of pancreatic diges- 
tion, and this is converted by the alkaline constituents of the blood 
into indican. A high temperature of the atmosphere, a meat diet, and 
other conditions increasing the acidity and density of the urine, raise 
the proportion of indican above the ordinary level, and in such patho- 
logical states as diabetes, cancer of the stomach, obstruction of the 
intestines, etc., it is so much greater than in health as to have some 
value as a means of diagnosis. 

The presence of indican in the urine may be demonstrated as fol- 



THE URINE. 



507 



lows : Warm one drachm of strong nitric or hydrochloric acid in a 
test-tube ; then gently pour on the surface of the acid about the same 
quantity of urine (which must be free from albumin), and at the point 
of contact there will form a ring of color— violet, if but little indican 
is present ; and blue, if there be much. The indican may be separated 
by chloroform. The acid and urine are well incorporated by shaking 
them up in the test-tube, a little chloride of lime solution added until 
a greenish tint appears, and then the whole is agitated with two and 
a half drachms of chloroform. If allowed to stand undisturbed for a 
time, the chloroform will separate of a violet or bluish color, according 
to the quantity of indican dissolved in it. 

The Mineral Constituents— Phosphates.— The combinations of phos- 
phoric acid with the mineral bases of the body are of two kinds : alka- 
line and earthy— of potassium and sodium ; of calcium and magnesium. 
The alkaline phosphates are soluble, and do not, therefore, form a sedi- 
ment ; on the other hand, whenever the urine becomes alkaline, the 
earthy phosphates are precipitated. The acid reaction of normal urine 
is due to the presence of the acid phosphates of sodium and potassium. 
Under certain conditions, not well understood, these phosphates are 
not converted into acid salts, and then the urine becomes neutral in 
reaction. When the urine is distinctly alkaline on excretion, this re- 
action is due to the presence, in excess, of the alkaline carbonates, and 
then the urine effervesces on the addition of an acid. 

We owe to Dr. Gee* the demonstration of the remarkable fact, 
that in cases of ague the phosphoric acid disappears from the urine, 
or is greatly reduced in amount. In chronic albuminuria the alkaline 
phosphates are below the normal considerably. 

The earthy phosphates of systemic origin consist of calcium and 
magnesium phosphate. The ammoniaco-magnesium phosphate is pres- 
ent in large quantity in certain diseases of the genito-urinary tract, 
and it is then of local origin, or from the inflamed mucous membrane. 
Phosphate of lime is found in the urine in two forms : as amorphous 
granules, and as needle- and star-shaped crystals — the former in much 
greater quantity. When acid urine is boiled, the phosphates being in 
excess, a cloud appears, which is dissolved, and the urine made clear 
by the addition of a few drops of nitric acid. If the urine is alkaline, 
the phosphates may be sufficient to give it a turbid appearance, or even 
to make it thick and white. It sometimes happens that an abundant 
precipitate of the phosphates takes place in the bladder, and the urine 
last passed is then thick, white, and ropy, and voided with difficulty. 
This condition of things is alarming to the patient, and may be per- 
plexing to the physician, until, on the addition of nitric acid, the whole 
sediment disappears. If effervescence is produced by the addition of 



*"St. Bartholomew's Hospital Reports," vol. viii. 



608 



DISEASES OF THE KIDNEY. 



acid, it may be concluded that the bicarbonates of potassium and so- 
dium are present in excess. 

The ammoniaco-magnesium phosphate, or triple phosphate, is found 
in the urine when it has been rendered alkaline by ammonia. The am- 
monia is a product of the decomposition of urea, the mucus present play- 
ing the part of a ferment. The crystals of triple phosphate are trian- 
gular prisms, and are readily recognized under the microscope. Like 
the other phosphates, this is dissolved by a mineral acid. 

.Phosphorus, unoxidized and in combination with organic substances, 
as lecithin, appears in the urine. The quantity present is estimated by 
converting it into phosphoric acid by an oxidizing agent. In health 
the amount excreted by the urine is very minute, but in certain dis- 
eases characterized by destructive changes in the brain substance, in 
phthisis, in pernicious anfsemia, etc., it is greater. 

The Sulphates. — The sulphates consist of combinations of sulphuric 
acid with potassium and sodium, and, to a much smaller extent, of cal- 
cium. In health the amount of sulphates excreted is largely influenced 
by diet, especially animal food. In disease they are increased by the 
inflammatory process, notably pneumonia, meningitis, etc. 

The Chlorides. — The chief chloride salt is chloride of sodium, and 
the quantity of this excreted is much affected by the amount of com- 
mon salt taken with the food. A portion of the salt eaten is, how- 
ever, converted into chloride of potassium. From one to two drachms 
is excreted in twenty-four hours. The test for chlorides is nitrate of 
silver. The urine to be examined is first acidulated with nitric acid 
to keep the phosphates dissolved, and then solution of nitrate of silver 
is added, whereupon an abundant white, curd-like precipitate of chlo- 
ride of silver falls. This precipitate is not soluble in excess of nitric 
acid, but is dissolved by ammonia in excess. 

It has been ascertained that the chlorides disappear from the urine, 
or are, at least, greatly reduced in amount, during the progress of an 
acute inflammation. In pneumonia this change in the quantity of 
chlorides becomes a prognostic indication of some value, for disap- 
pearing as the lung becomes hepatized, they suddenly reappear with 
the occurrence of the other critical phenomena. 

Adventitious Substances. — Diagnostic, prognostic, and therapeutic 
indications of great value are obtained from, the examination of cer- 
tain adventitious materials which may be present in the urine. 

Albumin. — Many tests have been proposed for serum albumin, but 
it is quite certain that none of them are as accurate as the application 
of heat. Much depends on the mode of employing it. The following 
method is the best : 

Half fill a medium test-tube wnth the suspected urine. Heat it to 
the boiling-point. If the urine is decidedly alkaline in reaction, and 
no cloudiness appears, add sufficient nitric acid to change the reaction 



THE URINE. 



509 



to acid, and then boil again. If now no cloud appears, the urine does 
not contain albumin. If the urine is neutral or acid in reaction, and 
on boiling a milky cloudiness becomes manifest, add some nitric acid, 
drop by drop, by means of a pipette. If the urine clear up, the pre- 
cipitate is not albumin, but most probably phosphates. When the urine 
under examination is cloudy from the presence of mucus, it should be 
filtered ; if from urates, heating will redissolve them, and the urine be- 
come clear before it gets cloudy again from coagulation of the albumin. 

Heller's nitric-acid test is very convenient, but its value is impaired 
by several possible fallacies. It consists in the coagulation of the albu- 
min by nitric acid. Thirty minims of pure acid are put in a test-tube, 
and about the same quantity of urine is allowed to flow gently on to the 
surface of the acid, where, if albumin be present, a whitish coagulum 
appears, which is not dissipated by heat. Hydrated uric acid, and 
amorphous urates, may furnish a similar zone to that made by albu- 
min, but these disappear on heating. 

Johnson's picric-acid test is delicate, and, if confirmed by the action 
of heat, is certain. It is applied as follows : A saturated solution of 
picric acid is made by dissolving six to seven grains in an ounce of 
boiling distilled water, and this solution is poured on some of the sus- 
pected urine contained in a test-tube. If the resulting yellowish coagu- 
lum is not dissolved by heat, it consists of albumin. 

Probably the most sensitive of all the tests for albumin is Tanrefs 
pot assio-mer curie iodide. It consists of the following ingredients : cor- 
rosive chloride of mercury, 20 grains ; iodide of potassium, 50 grains ; 
acetic acid, 6 drachms ; and sufficient distilled water to make up to 
2J pints. This precipitates albumin, and also peptones, alkaloids, and 
urates ; but heat dissolves all these, except albumin. 

The albumin ordinarily present in urine in disease is serum-albumin 
— the albumin of the serum of the blood. 

Acid-albumin^ or syntonin, is occasionally encountered when the 
urine is highly acid. It is not precipitated by heat until the acidity 
of the urine is lessened, which may be effected by the careful addition 
of sodium- carbonate solution. Alkali- albumin, or casein, also fails to 
be precipitated on boiling, unless some drops of acid are added to 
neutralize the urine. 

Paraglobidin is found in albuminous urine associated with serum- 
albumin, and may indeed be in excess of the latter. Very rarely it 
appears alone in the urine, and is mistaken for albumin. In cases of 
albuminuria due to amyloid degeneration, and of scarlatina nephritis, 
and in temporary albuminuria caused by derangement of the digestive 
organs, paraglobulin may be in excess. It is separated from serum- 
albumin by treating the urine with sulphate of magnesia to the point 
of saturation, when the paraglobulin is cast down. . 

Peptones are also often found, usually with albumin, but may be 



510 



DISEASES OF THE KIDNEY. 



present without it. The most delicate and convenient reaction for 
distinguishing peptones in the urine is that devised by Dr. Randolph, 
of Philadelphia, and is based on the fact that, when acid mercuric 
nitrate is added to a solution of iodide of potassium, red mercuric 
iodide is precipitated ; but if peptones or bile be present, the precipi- 
tate is yellow. It is necessary, then, to determine whether the bile 
acids are present by the appropriate tests. 

Peptones are present in the urine in cases of acute septic diseases, 
such as diphtheria, variola, and cerebro-spinal meningitis, and when 
pus or inflammatory exudates are absorbed, as, for example, in cases 
of croupous pneumonia, pleuritis, and rheumatic effusions. 

In the sections devoted to diseases of the liver, the reactions due to 
the presence of hile pigment and acids are given. It is necessary, how- 
ever, to say something of leucin and tyrosin. These are found to- 
gether in the urine when the liver-structure has undergone extensive 
injury, as in acute yellow atrophy, in phosphorous poisoning, and in 
malignant typhus. These substances take the place of urea. For the 
methods of their detection and appearance under the microscope the 
reader is referred to works on urinary analysis. 

Sugar. — It is now commonly held that sugar is present in very 
minute quantity in normal urine. ^Nevertheless, any amount above 
the merest trace must be regarded as pathological. The tests most 
in use are three : Trommer's, Fehling's, and fermentation. 

As in the application of Trommer's and Fehling's the results may 
be vitiated by the action of the urates, it is necessary to remove them 
before applying the reagents. This is accomplished by precipitating 
them with acetate-of-lead solution, and then filtering. In using Trom- 
mer's test, the following method is pursued : To the urine in a test- 
tube is added a few drops of the solution of cupric sulphate, or a pel- 
let of the same. The sulphate is converted into the oxide by liquor 
potass^e, which is poured in until the first precipitate is redissolved. If 
sugar be present, the oxide of copper is reduced to suboxide on warm- 
ing the liquid, and this reaction is manifest by the appearance of a 
reddish precipitate. If the reduction of the copper does not take 
place on warming the liquid, sugar is not present, although on pro- 
longed boiling the reaction may occur. 

Fehling's differs from Trommer's test in that the potassio-tartrate 
of sodium (Rochelle salt) is added to the alkaline copper solution. If 
the solution be kept for any considerable period, it becomes so changed 
as to be unreliable, and should be boiled before using as a test, since 
the copper may be reduced thus. Pellets of copper sulphate and of 
sodic tartrate of potassium are now prepared separately, and are added 
to a solution of caustic soda when required for use. Solutions may 
also be kept separately, and mixed when needed. When a given speci- 
men is to be examined, Fehling's solution is heated to the boiling 



UREMIA. 



511 



point, and a drop of the urine is added, when a yellowish precipitate 
occurs if sugar be present in quantity, or greenish if the proportion of 
sugar be small ; but the yellowish tint is produced by putting in a few 
more drops of urine. , 



UREMIA. 

Definition— The retention in the blood of those excrementitious 
substances which it is the function of the kidney to remove is known 
as urcemia. Strictly speaking, this term signifies urea in the blood ; 
but, as urea is not the most offending substance, the extractives, and 
even the potash salts, according to Feltz, and other ingredients of the 
urine being poisonous when retained in the circulation, the term 
uraemia has, by common consent, been extended to include the com- 
plexus of symptoms due to the presence of the urinary constituents in 
the blood. 

Pathogeny. — The retention of the urinary constituents may be due 
to insufficient secretion or to imperfect excretion ; in the former, the 
materials which go to make up the urine are not separated from the 
blood ; in the latter, after the urine has been duly formed, its excre- 
tion is prevented, and resorption into the blood occurs. In the vari- 
ous forms of albuminuria, ursemia is due to insufficient secretion, and 
imperfect excretion results from obstructive disease of the ureters, of 
the bladder, of the urethra, and from exterior pressure, as in the case 
of tumors encroaching on the urinary passages. 

The diminution* of the urine, which is concerned in the production 
of ursemia, consists in the lessened excretion of the solids. The urinary 
water may, in respect to bulk, be fully up to, even exceed, the normal, 
and yet symptoms of ursemia occur, because of the insufficient depura- 
tion of the urinary excrement. Great differences of opinion have ex- 
isted, since the time of Bright's discovery, in regard to the particular 
urinary constituent causing the secondary disturbance. Christison 
was the first to express the idea of a connection between certain ner- 
vous phenomena and the condition of albuminuria, and he referred 
these phenomena to blood-poisoning caused by the retention of urea, 
but he also held that there was an excessive excretion of the coloring 
matter to which the disturbance was in part due. Hammond, and sub- 
sequently Richardson, maintained that the retention of urea is the real 
cause. Frerichs then brought forward his carbonate-of -ammonia the- 
ory. He showed, what subsequent observers have confirmed, that urea 
itself injected into the veins is not injurious, and hence suggested 
that the real poisonous principle is carbonate of ammonia, since con- 
vulsions are produced when this substance is thrown into the veins, 
and it is found in the blood in ursemia. Against Frerichs's theory were 
opposed the insuperable objections that ammonia is a natural constitu- 



512 



DISEASES OF THE KIDNEY. 



ent of the blood, and that not more of it is found in the blood of ani- 
mals from which the kidneys have been removed than in the normal 
state. Treitz enlarged Frerichs's ammonia theory so that it included 
more facts, but it is not satisfactory. Treitz held that carbonate of 
ammonia is the toxic agent, but maintained that urea, excreted by the 
mucous membrane of the intestinal canal, is there decomposed, and 
diffused thence into the blood. Schottin next proposed that uraemia is 
due to the retained extractives, creatine, creatinine, etc., which are prod- 
ucts of tissue metamorphosis, that later in the process of hystolytic 
transformations are converted into urea. Although these substances 
may be noxious when retained, the theory which restricts the phenom- 
ena of urseraia to their retention is insufficient in scope. Traube has 
also propounded a theory, in which doubtless there is a measure of 
truth, since it is supported by the only lesion which is really referable 
to the condition of ursemic intoxication, namely, oedema of the brain. 
By reason of the watery state of the blood, transudations of serum 
take place through the cerebral capillaries, producing oedema of the 
brain. ^V^ith the increase of fluid in the perivascular lymph-spaces, 
more and more pressure is exerted on the intra-cranial vessels, so that 
ultimately sufficient anaemia is produced to cause convulsions. The 
existence of more or less oedema of the brain is doubtless true, and 
this facilitates the action of the toxic agents, while it is in part a 
result of their action. The last theory to be referred to is that of 
Feltz and Hitter, which ascribes ursemia to the toxic action of the 
potash salts of the urine, retained in the blood. Unquestionably the 
nervous and other symptoms of ura3mia may be produced by injecting 
the potash salts into the veins. But, while this statement is admit- 
ted, it may also be affirmed that not to one, but to all of the retained 
constituents of the urine possessed of toxic activity, may be referred 
the phenomena of uraemia. When there are several capable of pro- 
ducing disturbance of this kind, it were wiser to include them all, 
and refer the condition of uraemia to the retention of the toxic 
urinary constituents. 

Symptoms. — Uraemia may be acute or chronic: the former occur- 
ring in those renal affections characterized by a sudden great diminu- 
tion or suppression of the urine ; the latter belonging to the chronic 
affections, such as chronic interstitial nephritis, in which the quan- 
tity of urinary solids is slowly reduced. Acute uraemia consists in 
sudden violent headache, vertigo, disordered vision, twitchings of the 
facial and otber muscles, followed by general convulsions of an epi- 
leptiform character. The convulsions may recur every few minutes 
or hours, and in the interval there may be coma, the condition of in- 
sensibility persisting until death, or until the renal functions or vica- 
rious discharges are reestablished. The convulsions may exist with- 
out loss of consciousness, and in some cases assume a tetanic rather 



UREMIA. 



513 



than an epileptic type. Tlie acute form may also occur without con- 
vulsions, the patient passing from a state of somnolence into profound 
coma, in which the face is pallid ; the pupils are dilated, but react to 
a strong light ; the pulse is slow ; the respirations are shallow, often 
irregular (Cheyne-Stokes), and sometimes stertorous ; and there is 
general muscular resolution, but not localized paralysis. From this 
condition the patient may emerge, some hebetude of mind and diminu- 
tion in general and special sensibility remaining for some minutes or 
hours, and then recurrences of the coma and periods of improvement 
until the end. In other cases this comatose form of acute uraemia is 
varied by attacks of a convulsive character or by a mild delirium. 

Acute uraemia assumes still other forms, which, however, are ex- 
tremely rare. There is a delirious form, in which the mental trouble 
assumes the shape of a tranquil delirium, less often of acute mania, 
and is preceded by headache, disorders of vision, by a listless apathy, 
dullness of apprehension, and weakness of will. There is a dyspnoeic 
form, characterized by the sudden onset of intense dyspnoea without 
any change in the respiratory organs, but accompanied by a hoarse 
voice and sibilant inspiration, and terminating in a fatal coma. 

The chronic form of uraemia is characterized at the outset by 
symptoms referable to the digestive organs— dyspepsia, nausea, and 
vomiting, without apparent cause. With these stomachal symptoms 
are associated headache, vertigo, and dimness of vision. The head- 
ache is very intense and persistent, and is often frontal, and accom- 
panied by a band-like feeling. Early changes occur in the retina — a 
form of retinitis, known as retinitis albumin urica — which is often 
diagnosticated by the ophthalmologist before the urine has been ex- 
amined. Drowsiness is soon experienced. At first the patient falls 
asleep early in the evening, but after a time he dozes at all times in 
the day whenever his attention is not attracted by objects of interest. 
All of his special senses become dull, but vision suffers chiefly, hemi- 
opia and diplopia being the most usual forms of derangement. Mean- 
while the nausea and vomiting increase, the headache becomes more 
severe, vision grows more obscure, and presently muscular cramps 
occur at night, and twitchings of the facial muscles are observed at 
various times. Then develop the symptoms already described under 
the acute form. 

Course, Duration, and Termination.— The progress made by a case 
of uraemia depends on the changes occurring in the kidneys. In a 
fatal case of acute Bright's disease, the duration of the urjemia in the 
severe form will not be greater than from three to five days. There 
are rapid cases, which terminate fatally in a few hours. The chronic 
form may occupy weeks or months. In the acute forms of Bright's 
disease opinions in regard to the ternunation of uraemia must be ex- 
pressed with caution, since, under the proper treatment, very formida- 



514 



DISEASES OF THE KIDNEY. 



ble symptoms may disappear and health be restored. This statement 
is especially true of scarlatinal and pregnancy albuminuria. In chronic 
interstitial nephritis, in amyloid disease, and other fatal diseases, the 
appearance of ursemia is significant of a fatal termination. The 
chronic form of uraemia is, therefore, more serious than the acute. 

Diagnosis. — The state of the urinary secretion is the first ele- 
ment in making a diagnosis. Is the secretion suppressed ? Does the 
urine contain albumen or morphotic constituents, indicating structural 
changes in the kidneys ? Albumen and casts wanting, does an analy- 
sis reveal a notable diminution in the solids of the urine ? As regards 
the cerebral symptoms of uraemia, two points are especially significant: 
the absence of motor paralysis and of fever, which prove that menin- 
gitis, haemorrhage, encephalitis, etc., are not the causes of the disturb- 
ance. That opium, belladonna, strychnine, and other narcotic poisons 
are not concerned in producing the phenomena of uraemia, is evident 
from the history of the case and .the state of the urine. In every case 
of convulsions or sudden insensibility, not explainable by known con- 
ditions, if the urine has not been preserved, the catheter should be 
promptly used. If unconsciousness has been produced by a narcotic 
poison, the nature of it may sometimes be determined by injecting 
some urine under the skin of an animal. 

Treatment. — As uraemia is due to the retention in the blood of 
excrementitious matters which ought to have been separated by the 
kidneys, obviously some mode of vicarious relief becomes necessary. 
By the skin and intestinal canal, excretion may be in considerable 
part effected. By the vapor-bath, and pilocarpine subcutaneously, 
the skin may be efficiently acted on. When the heart is weak, pilo- 
carpine must be cautiously used ; also, in case there be much bronchial 
mucus and weak respiratory muscles, this agent may not be safe. 
When no contraindication exists to its employment, there can be no 
question in regard to the good effects produced by it. As urea and 
the product of its decomposition — carbonate of ammonium — is elim- 
inated by the gastro intestinal mucous membrane, when excretion 
by the kidneys is stopped, we may imitate the method of nature, and 
free the blood of excrementitious matters by purging. For this pur- 
pose the compound jalap powder, podophyllin, calomel (cautiously), 
may be used. The kidneys may be stimulated to better action, when 
not too far gone, by the administration of saline diuretics, infusion of 
digitalis, etc. When convulsions occur, more prompt means of relief 
become necessary. The inhalation of chloroform is an excellent expedi- 
ent, and is free from danger, if judiciously conducted. The hypoder- 
matic injection of morphine, as proposed by Loomis, is a valuable expe- 
dient, if it may seem rather heroical. He advises the injection at once 
of a half -grain of morphine for an adult, and this is repeated two or 
three times if necessary. The author has seen cases yield to this which 



CONGESTION OF THE KIDNEY. 



515 



continued under chloroform inhalations. This method is adapted to 
the cases of acute uraemia. Morphine thus administered seems to an- 
tagonize the condition of the cerebral vessels induced by uraemia, re- 
moves the oedema of the brain, and starts the kidneys secreting again. 

CONGESTION OF THE KIDNEYS— ACTIVE. 

Definition. — Hypersemia of the kidneys signifies an increased 
amount of blood in the organs. The hypergemia may be in the arte- 
rial supply — active congestion, or in the venous supply — passive con- 
gestion. 

Causes. — Active congestion is usually caused by some irritating 
substance which is eliminated by the urine. Various medicinal agents^ 
containing an essential oil, or a camphor, as copaiba, cubebs, eucalyp- 
tol, etc., excite irritation in the kidneys, as these substances pass through 
in the process of elimination. Turpentine and cantharides are among 
the most active of these agents, and more frequently cause acute 
congestion than any other. A mustard-plaster may also have the 
same effect, due doubtless to the absorption and elimination of the oil 
of mustard. An extensive burn, a counter-irritant affecting a consid- 
erable extent of surface, and possibly other injuries or impressions on 
peripheral nerves, may induce a reflex paresis of the arterioles of the 
kidneys. 

Symptoms. — More or less pain, sometimes very acute pain, is felt in 
the region of the kidneys, and extends downward along the course of 
the ureters, into the hips, through the bladder, which becomes very 
irritable, and into the testicles and penis. There is present an inces- 
sant and very pressing desire to pass water, which is high-colored, and 
rather scanty each emission, although in the aggregate up to the nor- 
mal. The urine may contain blood, or but a few red globules, or 
simply fibrin and casts, some cells of renal epithelium and albumin. 
If the action of the cause continue, the state of hyperemia will pass 
over into some of the forms of inflammation. The author is con- 
vinced that the persistent use of copaiba has kept up an hyper^Bmia, 
out of which has developed the chronic form of Bright's disease. If 
the agent producing the hyperaemia is withdrawn, irritation subsides 
in two or three days, and health is restored. 

The only treatment required in the mildest cases is to withdraw 
the irritating agent, to dilute the urine by the free administration of 
lemonade, or Yichy water, or Bethesda water. If there are decided 
irritability of the bladder and much pain, relief is quickly afforded by 
the administration of two or three grains of camphor every four hours, 
or still more promptly and efficiently l)y the hypodermatic injection of 
one twelfth of a grain of morphine, or by the stomach administration 
of one sixth to one fourth of a grain. 



516 



DISEASES OF THE KIDNEY. 



CONGESTION OF THE KIDNEYS— PASSIVE. 

Causes. — Passive congestion of the kidneys is caused by venous 
stasis. The chief lesions inducing venous stasis are obstruction and 
regurgitation of the mitral orifice, obstructive diseases of the lungs, 
obstruction and regurgitation at the tricuspid orifice, compression of 
the ascending vena cava above the renal veins, and thrombosis of the 
renal veins. 

Pathological Anatomy. — The vessels are abnormally full, and hence 
the organ is larger, and more blood flows out on section. As there is 
a moister state of the organ, owing to mechanical effusion from the 
swollen veins, the capsule is easily detached. The parenchyma of the 
organ is darker, having a bluish aspect ; it is moist and smooth ; the 
glomeruli are not swollen and congested, but the vessels of the convo- 
luted tubes are distended. The stellate vessels of the surface can be 
traced with the eye into the anastomoses of the interfascicular veins, 
and the vessels of the vasa recta are recognized as dark reddish stria- 
tions (Rindfleisch). If hypersemia becomes chronic, the over-supply of 
venous blood leads to important nutritional alterations — to hyperplasia 
of the connective tissue — and hence the whole organ increases in size, 
firmness, and weight. 

Symptoms. — ^In cases of passive congestion of the kidneys, the cen- 
tral disorder quite masks the changes occurring in the kidneys. When 
dropsy occurs, attention is directed to the state of the urinary secre* 
tion, but previously no symptoms had arisen indicating that the kid- 
ney was suffering. Besides the venous stasis and increased pressure in 
the venous system, the disturbance in the urinary function is in part 
due to the diminished pressure in the arterial system. The urine is 
scanty, dark in color, and acid in reaction. On standing, a very abun- 
dant deposit of urates takes place, and the urine becomes thick. The 
specific gravity is increased in the ratio of the decrease in the urinary 
water, and is 1025 to 1035, but it is also high because of the quantity 
of solids, uric acid, notably of urea, which may rise to five per cent., or 
higher. An important change now is apparent in the composition of 
the urine — it contains more or less albumin, but not often any consid- 
erable amount. If such urine, thick and dark, is placed in a test-tube 
and gently heated, it will soon clear up, except some fine particles, but 
gradually, the heat continued, the clear urine will become milky, from 
the coagulation of albumin. The urates dissolve at the temperature 
below the coagulating point of albumin. On microscopic examination 
the morphotic elements present in the urine consist of a few red blood- 
globules, some tubular epithelium, and a few delicate, transparent 
casts. The amount of albumin present in such urine does not often 
exceed one per cent. 

Course, Duration, and Termination. — The kidney complication in 



ACUTE PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 517 



cardiac and pulmonary obstructive disease follows the fortunes of the 
central lesion. When the cardiac lesion is compensated, and the pres- 
sure rises in the arterial and falls in the venous system, the congestion 
of the veins and the ischaemia of the arteries of the kidneys will cease 
— the urinary water will increase, and the albumin will disappear. If, 
however, the central lesions be permanent, the condition of the kidney 
will grow worse, the albumin increase, and, after a time, the specific 
gravity will fall. Cerebral symptoms do not arise from venous conges- 
tion of the kidney, because the tubular epithelium remains sound and 
whole, and therefore equal to its function of excreting excrementi- 
tious materials. Death may occur from some intercurrent malady, or 
the patient die exhausted from the persistent dropsical accumulation. 

Treatment. — The management of passive congestion of the kidneys 
is that of the central lesion. It includes the use of digitalis, quinine, 
and iron, of hydragogue cathartics, of warm baths, vapor-baths, and 
pilocarpus, caffeine, convallaria, nitro-glycerine, of diuretics, etc. The 
condition of the kidneys is improved by those remedies which affect 
the heart trouble favorably. The account already given of the treat- 
ment of cardiac disease with dropsy is equally applicable here. 

ACUTE PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 

Definition. — Under the head of " Bright's Disease" there are in- 
cluded several acute and chronic affections of the kidneys, which agree 
in the one important characteristic of the urine containing albumin. 
According to many authorities, acute parenchymatous nephritis is the 
first stage of Bright's disease : it is " the large, white kidney," " the 
large, smooth kidney " of English authors, and corresponds to John- 
son's " acute desquamative nephritis." Although Charcot adopts the 
term " parenchymatous nephritis," he holds that we are not yet pre- 
pared to name it accurately.* By Bartels it is designated " acute 
parenchymatous nephritis " ; by Millard, " croupous nephritis " ; the 
latter is the more happy term. 

Causes. — To this form of nephritis youths are more liable than the 
aged. An exception to this exists in infants, and the liability con- 
tinues till middle life, and, indeed, though greatly diminished, does 
not entirely cease after this period. Heredity appears to have an in- 
fluence, although the facts are not numerous. Type of constitution 
seems very important among the causes. The pale, light-haired, full 
but flabby subjects of the albuminous type seem to have a special sus- 
ceptibility to this form of nephritis. Those substances which cause 
active hyperjemia of the kidneys, as cantharides, turpentine, copaiba, 
etc., will induce inflammation of these organs, if they continue in 
action for a sufficient time. Scarlatina is probably the most common 

* On " Bright's Disease," translated by Millard. New York : William Wood & Co. 



518 



DISEASES OF THE KIDNEY. 



cause. It is not the character of the epidemic, nor the severity of the 
attack itself, which wholly determines the changes in the kidneys, for 
the mildest epidemics and the least pronounced cases may be remark- 
able for the extent of the renal complication ; yet, if the epidemic have 
a malignant aspect, there will be more formidable cases of nephritis. 
As not all cases of scarlatina are accompanied by the renal disease, 
there must be some inherent bodily condition, or peculiarity in the 
structure of the kidneys, to account for the result. The same is true 
of diphtheria, in which an inflammation of the kidneys occurs in a pro- 
portion of the cases. But in diphtheria there seems to be a relation 
between the severity of the systemic poisoning and the occurrence of 
the renal complication. Oertel maintains that the disease of the kid- 
neys is due to the transference to these organs of " bacterian colonies " 
and their subsequent multiplication. In diphtheria, more than in scar- 
let fever, there may be albumin in the urine, without recognizable 
changes in the structure of the kidneys. In analogous morbid states 
acute parenchymatous nephritis may be produced. These are typhoid, 
erysipelas, malignant pustule, etc. — diseases due to the reception and 
development of some specific infective material which, eliminated by 
the kidneys, excites inflammation in passing through these organs. 
The skin and kidneys stand in intimate functional relation to each 
other, and when one is inactive the other may act vicariously in its 
stead. This physiological fact has a corresponding pathological rela- 
tion. Acute nephritis may be excited by exposure of the body to cold 
when the skin is warm and perspiring. The sudden arrest of the skin 
secretion throws a greatly increased labor on the kidneys ; their ves- 
sels dilate, and an acute hyperjemia prepares the way for inflam- 
mation. Pregnancy is a cause of acute parenchymatous nephritis. 
Usually, but not invariably, it is the first pregnancy, and it is more 
common in twin pregnancies. It occurs in the thin, in the robust and 
plethoric, in those of low and high degree, and under the most varying 
conditions. Having occurred in one pregnancy it may happen again, 
and not unfrequently becomes a permanent malady pursuing a course 
independently of pregnancy. 'No satisfactory explanation has thus far 
been offered. That it occurs not more frequently than one time in 
one hundred and fifty pregnancies renders it probable that there must 
exist a renal or constitutional disposition which pregnancy excites into 
activity. 

Pathological Anatomy. — The changes in the structure of the kid- 
ney in acute parenchymatous nephritis are much disputed. To render 
clear the form of the disease under consideration, it may be repeated 
that it is the large, pale, and smooth kidney of the English writers. It 
is increased in size, so that it may reach twice its normal weight and 
volume ; the cortex is pale, grayish-white, or a dull white ; it is 
smooth, because when the capsule is stripped off there are no pits or 



ACUTE PAEEXCHTMATOUS OR CROUPOUS XEPHRITIS. 



519 



elevations as occur in the contracted kidney, and its texture is rather 
soft. There is but little hypersemia of the cortex ; here and there 
dark-red points are seen, or punctiform extravasations ; but the pyra- 
mids are deeply congested, bluish red, or brighter red, and contrast 
strongly with the pale gray of the cortex. In other cases, according 
to Bartels, the cortex may not be so pale, may be reddish gray in con- 
sequence of a considerable hyper[emia, and there may be between this 
amount of congestion and the dead-white a great deal of variation. 

The changes ascertained on microscopical examination are found 
" localized almost exclusively in the convoluted tubes " (Charcot), and 
consist in cloudy swelling of the epithelium, which remains in situ. 
The change in the appearance of the epithelium — the cloudiness — is due 
to the deposit of fine granulations, and in such large numbers that the 
lumen of the canal is almost closed by the distention of the epithelial 
cells. The ends of the tubules are also sometimes blocked by the 
deposit of fibrin-plugs. The convoluted tubes also become dilated 
and varicose by reason of changes taking place in the proper tunics of 
these tubes. The appearance of the kidney thus affected may be 
changed by localized or extensive fatty metamorphosis — by fatty 
change limited to a few tubes here and there, or by a general fatty 
change. TThen thus altered the color becomes yellowish, and, if 
localized, gives to the organ a granular appearance, and hence the 
name applied to it by Johnson as the fatty granular kidney ; if gen- 
eral, it becomes the large fatty kidney. It has been much disputed 
whether the large, smooth kidney ever undergoes an atrophic change. 
It is held by Charcot that in very rare instances an atrophy may be 
effected by the liquefaction and disappearance of the fatty epithelium 
and the subsequent collapse of the tubules. 

Symptoms. — When parenchymatous nephritis occurs during the 
course of scarlet fever, diphtheria, and other febrile diseases, the symp- 
toms are modified in various respects. Two modes of onset are de- 
scribed when the disease occurs independently — one sudden, with high 
fever, aching pains in the lumbar region ; the other slow, obscure, and 
with little disturbance. The first variety usually results from taking 
cold ; the patient, while heated and perspiring, plunges into cold water 
or lies upon the damp ground, and in a short time — twelve to twenty- 
four hours — has some chilliness, even a rigor, followed by high fever, 
intense headache, pains in the lumbar region and through the limbs, 
nausea, vomiting, and anorexia. The symptoms which attract atten- 
tion to the kidneys in either mode of onset are the changes in the char- 
acter of the urine. In some cases the first symptom referable to the 
urinary organs is an extremely irritable state of the bladder, frequent 
desire to micturate ; a few drops only, and these it may be bloody, can 
be passed. This symj)tom does not last long, and is not common. 
Usually there are observed changes in the quantity of the urine, the 



520 



DISEASES OF THE KIDNEY. 



amount passed in twenty-four hours being variously reduced from 
forty ounces, the normal quantity for an adult, to twenty, ten, even five 
ounces, and at the same time important new constituents appear in the 
secretion. There may occur entire suppression, when the most formi- 
dable symptoms will arise, and death result in a few days. The urine 
at the onset often contains blood, when it presents various appearances 
according to the quantity present : it may have a faint, smoky tinge, 
or with this there may be an admixture of a reddish hue, or it may be 
distinctly reddish without the smoky hue, or it may be dark, reddish- 
brown, almost black. When permitted to stand, a quantity of urates 
fall, and with them various morphotic constituents, chiefly blood-cor- 
puscles, entire or disintegrated. The quantity of ui^ea, as compared 
with the amount of urine, is much less than normal ; uric acid is not 
less, but the saline constituents are reduced. The gross amount of 
solid constituents is, therefore, below the standard of health. The 
reaction of the urine is acid and the specific gravity is high, often 
reaching 1030, but this result is due to the diminished amount of 



water, since the solids in the aggregate are below normal. In the 
further progress of the case, as the amount of water increases, the 
specific gravity falls ; but there is an increase in the solids and in the 
urea in the aggregate, although the quantity of each is small in any 
single specimen of the urine. The decline in specific gravity may be 
from 1030 to 1005. With the diminution of specific gravity or increase 
of water the acid diminishes, the urine becoming very faintly acid or 
neutral. The most characteristic condition as regards the urine is the 
presence of albumin, in this affection ranging from distinct traces to 
three per cent. The albumin may be absent at the initial period, but 
only for a brief period, the aggregate amount of the urine being very 
small. Besides albumin and blood-globules, perfect and disintegrated, 
there are present casts of the tubules, of coagulated blood, and pale, 
transparent, hyaline casts, with an occasional epithelial cell adherent. 
The pale casts are usually few in number, but in the progress of the 
case they are supplanted by large hyaline casts and numerous large 




Fig. 37. — Casts of Acute Parenchymatous Nephritis. (Beale.) 



Fig. 38.— Epithelium from Convo- 
luted Tubes. (,Beale.) 



ACUTE PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 621 



granular casts. Usually, also, the sediment contains epithelial cells 
cast oft' from the tubes and granules in great numbers. Very often it 
is not until cedema of the ankles and feet appears that attention is 
called to the state of the urine, when it is found to be scanty. In 
consequence of the diminution in the amount of water separated by 
the kidneys, the condition of the blood and the rate of absorption, 
especially, the cellular tissue becomes oedematous ; if the patient is up, 
the water settles in the feet and legs ; if recumbent, it accumulates in 
the lumbar region and hips, and may first, or coincidently with its 
appearance elsewhere, manifest itself in the eyelids. Puffiness of the 
face, with a peculiar pallor of the skin, and broadening of the bridge 
of the nose, while the eyelids are swollen, present a striking appearance 
which can hardly fail to be observed, and may be the first indication 
of the oedema. The effusion extends, the subcutaneous areolar tissue 
becomes universally filled, and the great serous cavities are ultimately 
distended to their utmost. 

The retention in the blood , of the excrementitious substances in 
health discharged by the kidneys has a disastrous effect. The nervous 
system is poisoned, convulsions (eclampsia) occur and vary in severity, 
from twitching of the muscles of the face and of the extensors of the 
forearms to general convulsions involving loss of consciousness and 
clonic spasms of all the voluntary muscular system. The appetite is 
lost, and there are usually nausea and protracted vomiting, and some- 
times there is very troublesome diarrhoea. The loss of albumin and of 
blood and the poisoning of the blood by retained excrementitious mat- 
ters soon lower very seriously the nutrition of the body. Vision is 
impaired, both in consequence of simple ansemia of the retina and of 
the changes of albuminuric retinitis. 

Course, Duration, and Termination. — Those cases occurring sponta- 
neously are more acute in character, accompanied by fever and disor- 
ders of micturition, which attract attention to the kidneys. The fever 
does not continue longer than a few days. If there is complete sup- 
pression, the case may terminate fatally within a week. If, as is usual, 
the development is slower and the urine is greatly diminished in quan- 
tity, the amount of the dropsy will depend on the reduction of urine 
for a lengthened period. The promptness with which oedema appears 
is determined by the scantiness of the urine, so that well-developed 
dropsy may be produced in a week. When the cellular tissue and the 
cavities are filled with fluid, the duration of the case depends on the 
degree in which the kidneys can be made to functionate, for, although 
temporary improvement and alleviations may result from vicarious dis- 
charge of the urinary functions, results obtained in this way are not 
permanent. This form of nephritis is not nearly so fatal as the other 
forms ; indeed, the percentage of recoveries is quite large. When this 
disease occurs in scarlatina, it modifies the course of the latter mate- 
rially, and prolongs its duration. Death may ensue in convulsions, or 



522 



DISEASES OF THE KIDNEY. 



result from exhaustion in consequence of the protracted anaemia, and 
the gastro-intestinal disturbance, which prevents the retention and 
assimilation of food. Recovery may ensue after several weeks of 
dropsy, vomiting, and diarrhoea, interspersed with eclampsia, the conva- 
lescence being very slow. Three months or more may be occupied in 
the return to health. 

The Acute Parenchymatous Nephritis of Pregnancy. — There are 
points connected with this disease requiring special consideration in 
respect to its course and terminations. It is usually considered due 
to two factors — to the relatively poor quality of blood of pregnant 
women, and to the pressure of the enlarging uterus on the renal veins, 
causing passive congestion. As Bartels shows, the renal veins occupy 
a position which secures them against pressure, and, as so large a pro- 
portion of pregnant women escape the complication of albuminuria, it 
can hardly be due to either or both of the factors to which it is usually 
ascribed. There must be some special predisposition, and as the con- 
dition of the kidney is precisely the same as in the acute parenchyma- 
tous nephritis, and as it not unfrequently assumes the chronic form, 
pregnancy is merely an exciting cause. The change in the kidneys 
may take place in the early months of pregnancy, when visual disturb- 
ances, dropsy, and miscarriage will ensue, or later, when to the visual 
disturbances and dropsy must bo added eclampsia. (Edema of the 
face and limbs and frequent micturition are often the first symptoms, 
but, in the author's experience, visual disorders, especially hemiopia, 
double vision, and amblyopia, are very frequently the first departure 
from health.* Again, persistent huskiness of the voice may be the 
first indication. In other cases no symptoms are felt but disorders of 
digestion, and, as they are like those of the first months of pregnancy, 
little attention is paid to them, or there may be persistent headache 
with vertigo. Sometimes the first symptom to attract attention is an 
attack of convulsions, the health being apparently good. The urine 
usually contains an excessive quantity of albumin. The oedema is 
usually not great. The important point in these cases is the violence 
and acuteness of the uraemia, whether manifest in the form of convul- 
sions or maniacal excitement. The relative frequency of eclampsia in 
proportion to the whole number of cases of albuminuria is about one 
fourth, and of those attacked by eclampsia about one third die. The 
symptoms usually quickly subside on abortion or delivery, but a con- 
siderable proportion become chronic and prove fatal in subsequent 
pregnancies, f 

Treatment. — As the kidneys are in an irritated state, all stimulants 
to them should be avoided. To give them rest, vicarious functions 
need to be stimulated to the highest activity — notably the skin and 

* See " Die Albuminurie in ihren ophthalmoskopischen Erscheinungen," by Dr. Hugo 
Magnus, in which the changes in the retina wrought by albuminuria are well depicted, 
f Elliot, " Obstetric Clinic," chapter iii, New York, 1868. 



ACUTE PARENCnYMATOUS OR CROUPOUS NEPHRITIS. 523 



intestinal mucous membrane. When the symptoms are urgent, the skin 
may be excited by pilocarpine nitrate (y^ to -| gr. for an adult), or by 
the vapor-bath or warm pack. As Barker, of New York, has recently 
shown, pilocarpine must be used with caution in these cases on account 
of its depressing effect on the heart. Those purgatives are used that 
produce free watery evacuations. If the stomach is very irritable and 
the symptoms not urgent, small doses of calomel grain), frequently 
repeated, act extremely well. In acute uraemia, the most active cathar- 
tics are required — as elaterium, croton-oil, gamboge, etc. — since it is 
necessary to procure abundant watery evacuations. If the case does 
not require immediate active interference, the compound jalap powder 
is probably the most generally useful of the purgatives in this disease. 
It is best administered in the early morning, so that the disturbance 
produced by it may be ended before the time for the administration 
of the other remedies directed during the day. To relieve the kid- 
neys of congestion, and to remove obstructions from the tubules, 
diluents must be freely used. The most important diluents are milk 
and cream-of -tartar solution. If the stomach is irritable, milk may be 
given with lime-water, one fourth to one third of the latter. Infusion 
of digitalis may be given with cream-of-tartar solution, or alone ; but 
it is more effective in combination. If the stomach will not bear 
digitalis, it acts surprisingly well in the form of a poultice applied to 
the back or abdomen. Nitro-glycerine is very useful : it lessens the 
congestion of the kidneys, and diminishes the amount of albumin pres- 
ent in the urine. It is best given in the form of the centesimal (one 
per cent.) solution, commencing with one drop every four hours and 
adding a drop at each dose until the characteristic effects are produced. 

If eclampsia occur, what treatment is most effective ? If the sub- 
ject is plethoric, the superficial veins full, the conjunctiva injected, 
bleeding, by venesection, may be practiced with advantage. Chloro- 
form, by inhalation, can be used to abate the violence of the symp- 
toms, but as soon as possible a hypodermatic injection of morphine 
should be given according to the method of Dr. Loomis, of New York, 
who has shown that large doses are remarkably effective in arresting 
the convulsions of uraemia. Half a grain of morphine can be given at 
once, and it may be repeated in two or three hours, if necessary, until 
two grains have been taken. He shows that, if the first large dose is 
without effect, other doses should be administered fearlessly until the 
desired effect is produced. Warm baths and active purgatives are in- 
dicated, and must be energetically used. Excellent results have been 
obtained by the use of chloral by the stomach (gr. xv to gr. xlv) : it 
is even more effective by the rectum. Bromide of potassium may be 
given in full doses, with or without chloral, by the stomach or rec- 
tum, according to the condition of affairs. The same principles hold 
good in the treatment of the puerperal mania arising from uraemic 
intoxication. 



524 



DISEASES OF THE KIDNEY. 



CHRONIC PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 

Causes. — It is comparatively rare for the chronic form of paren- 
chymatous nephritis to succeed to the acute. It is a disease of youth, 
and is rare after forty. It arises from those causes which depress 
more or less permanently the vital forces, as syphilis, chronic malarial 
poisoning, protracted suppuration, chronic alcoholismus, chronic mer- 
curialismus, and other chronic poisoning by metals, etc. 

Pathological Anatomy. — To this form of diseased kidney is the term 
large, pale, or white, smooth kidney, especially applicable. One or 
both may be affected. The capsule is thin because of prolonged 
stretching, and, when divided, flies apart and is easily detached. The 
cortex is a dull, rather yellowish-white color, and is anaemic, while 
the pyramids are full of distended vessels and are dark red. The 
enlargement is due chiefly to an increased thickness of the cortical 
part. The epithelial lining of the tubules is not simply affected with 
" cloudy swelling," as in the acute form, but has undergone important 
changes — has been either detached, or is far advanced in fatty degen- 
eration, the cells being filled with fat-globules. The tubules contain 
a detritus, the product of the destruction of the epithelium, and 
consists largely of oil-globules, and they also are seen to be blocked in 
places by large casts. The intertubular matrix is also greatly thick- 
ened — a change due to hyperplasia of the connective-tissue elements, 
to the migration of the white corpuscles and their subsequent multi- 
plication and fatty transformation, and to a quantity of fluid exuda- 
tion, the product of the increased pressure in the veins. The Mal- 
pighian tufts and arteries are sometimes affected, according to Bartels, 
with the amyloid change in cases arising from chronic suppuration.* 
Undoubtedly, many tubules are rendered entirely and permanently 
useless, but restoration may take place when extensive changes have 
occurred in the kidneys. But, when the changes are too far advanced 
to permit recovery, the increase in the intertubular connective tissue 
and its subsequent contraction bring about an atrophic degeneration. 

Symptoms. — The approach of this form of kidney-disease is insid- 
ious. There is some decline in strength, the body is more easily 
fatigued, the mind is rather sluggish, and the appetite is poor. A 
condition of anaemia is evident, and the face has an earthy or fawn 
color, but it is not until oedema appears about the eyelids and ankles 
that advice is sought and the real nature of the case made apparent. 
The accumulation of fluid now proceeds rapidly, and in a short time 
the whole body is greatly swollen. The cellular tissue, the penis, and 
scrotum are immensely distended, and afterward the cavities fill up to 
their utmost capacity, and death may be soon caused by cedema of the 

* Rindfleisch, while admitting the existence of amyloid change, regards it as " infre- 
quent." {Op. cit.) 



CHKONIC PAREXCHYMATOUS OR CROUPOUS NEPHRITIS. 525 



lungs or paralysis of the heart. The dropsy in this form of nephritis 
assumes much greater proportion than that of the acute, or indeed of 
any form of nephritis. As the accumulation of fluid increases, the 
amount of urine discharged diminishes, but the urine falls off with the 
beginning of the renal lesions, although the change is not enough to 
attract attention. When the disease attains its maximum, the quan- 
tity of urine passed in twenty-four Lours becomes exceedingly small, 
and may not exceed four ounces, but there is considerable fluctuation, 
due to the variations in the amount of water. The urine has a darkish, 
smoky-looking color, which deepens as the quantity lessens. As the 
urine cools, it becomes thick with urates, ejjithelium, casts, etc. The 





.—Casts. (Beale.) 

sediment, which falls in great quantity, is composed of urates, uric 
acid, casts, white blood-globules, and granular detritus. The casts at 
first consist of pale, delicate hyaline cylinders, dotted here and there 
with oi] drops or granules, either long, narrow, and curved, or broad 
and shorter. The casts change in character with the progress of the 
case, becoming more granular, fatty, and the broad replacing the nar- 
row casts. The specific gravity of the urine changes with the variations 
in the quantity of urinary water, rising to 1035, even 1040, when the 
amount of urine discharged is very small. If, from 
any cause, there is a considerable increase in the 
quantity of urine, the specific gravity falls corre- 
spondingly, and below the normal. Albumin is al- 
ways present, but not in very great quantity, and 
fluctuates in amount with the variations in the spe- 
cific gravity. The same fact is true of urea, which, 
while constantly and absolutely below the normal, no. 40.— casts becoming 
varies with the changes in the specific gravity of the 
urine. The uric acid is increased, and probably in the ratio of the 
diminution of the urea. 

\yhen the dropsical accumulation has reached the maximum, the 
fluid is not limited to the subcutaneous tissue and the cavities. The 
mucous membranes become similarly affected. An early symptom 
may be a husky, even toneless voice, and dangerous laryngeal stenosis, 
from oedema of the glottis. The lungs become more or less oedema- 




526 



DISEASES OF THE KIDNEY. 



tous at the height of the disease, and life may he terminated by the 
accumulation of fluid in the lungs. The gastro-intestinal mucous 
membrane is also dropsical, and the epithelium, swollen, sodden, and 
degenerating, is cast off in large quantity. The result is vomiting of 
a quantity of serous fluid and profuse serous evacuations from the 
bowels, not only exhausting in themselves, but causing, ultimately, 
greater depression by interfering with digestion and the assimilation 
of food. The external integument is similarly affected. The epider- 
mis is sodden and detached ; the skin cracks in places, permitting the 
water to drain through ; and the true skin, irritated and exposed, be- 
comes exceedingly painful. This process takes place especially where 
the enormously distended scrotum lies on the swollen thighs. An 
extreme degree of anaemia results, from the operation of the various 
influences at work, in the digestive functions, in the assimilative func- 
tions, in the blood itself, and in the respiratory functions. The body, 
though puffed up with water, is thin, emaciated, and feeble. The 
pulse is small, compressible, and frequent. At the beginning of the 
disease, commencing rather abruptly in healthy and vigorous subjects, 
the pulse may be slow and full, and the heart-sounds sharply accentu- 
ated and loud, but, when well advanced, in all cases the pulse has the 
characteristics just mentioned, and the heart-sounds are feeble and 
obscure. When oedema of the lungs takes place, the respiration be- 
comes embarrassed ; but, if large serous accumulations occur in the 
pleural cavities and in the pericardium, the breathing becomes very 
diflicult, the patient is unable to lie down, and is tormented by a feel- 
ing of impending suffocation. Uraemia does not occur so frequently 
in the chronic as in the acute form of the disease, but amaurosis, mus- 
cular twitching, and partial and general convulsions do now and then 
take place. 

Course, Duration, and Termination. — Commencing insidiously, it is 
not until dropsical symptoms are manifest that the nature of the case 
is declared. Rarely does the disease come on with boisterous symp- 
toms, the body becoming rapidly distended. When the oedema is ob- 
served, there is no long interval in any case until the dropsy is general. 
When the maximum distention is reached, life can not long continue 
without relief. Dropsy, however, does not appear at once in every 
case — albuminuria may exist for months without any effusion, but, 
when this is the case, there may properly be a suspicion that an error 
of diagnosis has been committed. In favorable cases the dropsy will 
not be so great, and the kidneys will manifest a disposition to activity, 
and will respond to the action of medicines. Those are unfavorable 
cases in which the dropsical accumulation is extreme, and the kidneys 
are sluggish, but little urine passing, and in which these organs can not 
be induced to act efficiently. When there is pronounced dropsy, if 
the urine increases and the effusion diminishes, a year or more must be 
expected to pass before recovery can ensue. A complete recovery is by 



CHRONIC PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 527 



no means a rare event. Usually, vv hen the dropsy disappears, and con- 
valescence is apparently established, there are yet albumin and casts in 
the urine. If this is the case, the recovery is not real : there may be a 
slow return of flesh, the cachexia may diminish, and the strength im- 
prove, but a return of the dropsy may be confidently expected. Usually, 
when the albumin persists in the urine, the health is not restored when 
the dropsy disappears, but the body continues emaciated, and the pal- 
lor and anajmia remain. Death may be due to some intercurrent mal- 
ady — to an acute serous inflammation, to a low grade of pneumonia, 
etc. ; or the patient may be worn out and die by exhaustion ; or death 
may be due to urasmic coma. That the last-named accident does not 
occur more frequently is probably due to the fact that the excrementi- 
tious urinary substances are contained in the fluids of dropsy. 

Diagnosis. — When the symptoms occur suddenly, there is feverish- 
ness, the urine contains blood and pale casts, and there is pain in the 
back, the form of the disease is acute. If the symptoms come on 
slowly, there is no fever, no blood or epithelial cells are present in the 
urine, the quantity of albumin small and the specific gravity high, or 
over 1030, the form of the disease is chronic. In contracted kidney, 
the urine is pale, of low specific gravity, and contains waxy casts ; in 
chronic parenchymatous nephritis the urine is dark, of high specific 
gravity, and contains abundant large granular casts and epithelium : 
in the former there is but slight or no dropsical accumulation ; in the 
latter the dropsy is extensive. 

Prognosis. — Although rather unfavorable, the prognosis is not 
hopeless. Cases have recovered in which there had been very pro- 
nounced dropsy, and in which albumin had remained in the urine for 
months after the disappearance of the effusion. The more acute the 
symptoms and sudden the accumulation of fluid, the more favorable, 
provided the kidneys exhibit any activity. The prognosis is the more 
favorable, the shorter the duration of the disease, the less the urine de- 
parts from the standard of health, and the smaller the percentage of al- 
bumin. When the probable cause is remediable, as syphilis, or marsh- 
miasm, or lead-cachexia, the prognosis is favorable in proportion to the 
degree in which the morbid changes are due to the action of these causes. 

Treatment. — A dry, unchangeable, and warm climate exercises a 
most favorable influence on the course and termination of chronic 
parenchymatous nephritis, and is a remedial agent of the first impor- 
tance. When a suitable climate can not be obtained, the conditions 
which render it so useful should be applied to the patient, if practi- 
cable. He should be confined to bed, and remain between blankets, to 
secure warmth and uniformity. Free diaphoresis should be produced 
by warm air and by the administration of pilocarpus. If the accumu- 
lation of fluid is excessive, free purgation will be necessary, but this 
measure can not be continued for any lengthened period, since the 
implication of the mucous membrane is such that, without purgatives, 



528 



DISEASES OF THE KIDNEY. 



there occurs a highly irritable state of the intestinal canal. Besides 
diaphoresis, the only resource now remaining is, to stimulate diuresis. 
The choice of diuretics is restricted to those which do not increase the 
blood-pressure in the kidneys — as the free imbibition of fluids, milk, 
bitartrate-of-potassa solution, etc. The infusion of digitalis, notwith- 
standing the theoretical objections to it, is often very serviceable in 
exciting free diuresis. Combination with the bitartrate or acetate of 
potassa increases the action of both agents. If there be great disten- 
tion of the cavities and increasing difficulty of breathing, the aspirator 
may be used freely to draw off sufficient fluid to afford relief, but it is 
not desirable to empty the cavities. The removal of the fluid in the 
peritoneal cavity usually suffices, since the upward pressure of the 
ascites is the chief factor in the difficulty of breathing. Puncture of 
the skin may be necessary when the penis and scrotum are greatly dis- 
tended, but care must be used lest sloughing follow. A small sewing- 
needle is employed to puncture the skin, but Southey's trocar may 
be used, as it is a neat, elegant, and efficient instrument for the pur- 
pose. If the fluid can be removed by the application of these reme- 
dies, iron should now be used to correct the anaemia. Combination 
with iron increases the action of diuretics. As the presence of albu- 
min after the disappearance of the dropsy indicates the persistence of 
the mischief in the kidneys, it is then necessary to employ remedies to 
check the waste of material and to remove the cause on which it de- 
pends. This is a difficult if not an impossible task. The author has 
had promising results from the careful administration of tincture of 
cantharides — five drops ter in die, and continued, if the results are 
favorable, for several months ; still more valuable has proved the 
chloride of gold and sodium, with or without a minute quantity of 
corrosive sublimate — grain of the former and -^^ grain of the latter 
ter in die. Recent reports have favored the use of methaniline, but the 
author's experience has not been confirmatory. Good results have 
also been claimed for the Blatta Orientalis — the cockroach — a new 
remedy which comes to us from Russia. 

INTERSTITIAL NEPHRITIS— SCLEROSIS OF THE KIDNEYS. 

Definition. — Interstitial nephritis is one of the chronic forms of 
Bright's disease. Various designations have been applied to it : fi- 
broid kidney, renal cirrhosis, contracting kidney, granular kidneys, etc. 
The terms above given — interstitial nephritis and sclerosis of the kid- 
neys — are correct, since they designate the seat and character of the 
morbid change — an inflammation of the connective tissue of the kid- 
ney, the subsequent atrophy being due to the contraction and pressure 
of the new elements. 

Etiology — This disease, like its congener, sclerosis of the liver, is a 
malady of middle life, according to Dickinson occurring with greatest 



IXTERSTITIAL NEPHRITIS. 



529 



frequency at fifty, and rarely before twenty. As regards sex, this dis- 
ease is twice as frequent in men as in women (Dickinson *), and, ac- 
cording to German writers, four times more frequent in men (Bartels). 
Social condition does not appear to have any relation to its produc- 
tion, as it occurs under all circumstances in life. Gout seems to have 
an important position as a cause ; in sixty-nine fatal cases there were 
sixteen due to or accompanied by gout (Dickinson). The gouty con- 
dition is produced in a considerable proportion of those exposed to 
emanations from lead, and gouty kidney or granular kidney occurs in 
an astonishingly large number of such subjects. Out of forty-two work- 
ers in lead, dying from various causes in St. George's Hospital, twen- 
ty-six had granular kidneys (Dickinson). Lead-poisoning ranks first 
as a cause of this disease. It is in a high degree probable that chronic 
poisoning by other metals may exert a similar if not so predominant 
an influence in the production of this disease. Drs. Da Costa and 
Longstreth,f in a paper on "The State of the Ganglionic Centers in 
Bright's Disease," demonstrate the existence of degenerative changes 
in the renal ganglia. The ganglia undergo fatty degeneration and 
atrophy, the connective-tissue hyperplasia and the new elements pass 
through the same process. These lesions appear to the authors of 
the paper to stand in a causal relation to the renal affection. These 
observations have been confirmed by Dr. Saundby I , except that he 
regards the change as one of pigmentary degeneration. 

The author has maintained for many years that interstitial nephri- 
tis frequently follows gonorrhoea in consequence of the injurious action 
on the kidneys of the oils and balsams used in its treatment. Lieber- 
meister and Bartels have lately suggested that this relation between 
gonorrhoea and nephritis exists, but they suppose a transference of the 
catarrhal process from the bladder to the kidneys. 

Pathological Anatomy. — When the disease is far advanced, the 
kidneys, usually both, are very much reduced in size, from six or five 
ounces to three or two. From this extreme to a size equal to or a little 
greater than the normal, the gradations are numerous. Usually both 
kidneys are equally affected, but it sometimes happens that the disease 
is more advanced in one. The capsule is thickened, opaque, and some- 
what adherent. The surface of the kidney presents agranular aspect, 
due to the formation of a great number of spherical prominences, one 
tenth of an inch in size generally, but they may be either larger or smaller 
than this figure. These prominences are grayish in color and without 
vascularity, but the depressions between them are very vascular. Cysts 
of various sizes and in varying numbers are seen here and there on 
the surface ; they are clear, transparent, and of a straw-color. On 

* " The Pathology and Treatment of Alburninuria," p. 124. 
f " The xVmerican Journal of the Medical Sciences," July, 1880. 
X " The British Medical Journal," January, 1883. 
36 



530 



DISEASES OF THE KIDNEY. 



section, the tissue of the kidney is found to be tough and resistant. 
The cortical portion is thin by reason of atrophy, a line or two in thick- 
ness only remaining. The color is dark-brownish, or reddish-brown, 
or a yellowish-gray or fawn color, the variations being due chiefly to 
the amount of blood present in the organ. On microscopic examina- 
tion, the connective tissue about the Malpighian bodies and the blood- 
vessels and beneath the capsule is thickened, and the tubes are com- 
pressed into mere threads. Here and there may be a tube complete, 
its epithelium intact, but large spaces exist between, consisting exclu- 
sively of fibrous tissue, with the mere remains of wasted tubes. The 
glomeruli are grouped in bunches owing to the wasting of the interme- 
diate tubes, and lie imbedded in the fibrillated connective tissue. Cut 
off from the tubular connections, in some of them fluid accumulates, 
forming cysts. Interior cysts as well as those on the exterior are, 
however, chiefly developed from obstructed tubules. 

The changes are not always general, but may take place in parts 
of the organ ; one extremity may be small, contracted, granular, the 
other presenting its normal appearance ; the hilus may be the seat of 
the change and the rest of the organ be affected in patches. These ex- 
amples of irregularity in the development of the sclerosis are further 
irregular in the fact that the kidneys are unequally involved in the 
morbid process. The pathological alterations are not limited to the 
kidneys. The left side of the heart is hypertrophied, and this suc- 
ceeds to or is associated with hypertrophy of the muscular fiber of the 
arterioles throughout the body. The retina undergoes a form of in- 
flammation resulting in atrophy of the optic disks, known as retinitis 
albuminurica. The changes in the vessels are an influential factor in 
the production of the cerebral haemorrhage with which this disease 
not unfrequently terminates. 

Symptoms. — The development of this disease is so slow and from 
such small beginnings that it is usually far advanced before any symp- 
toms arise indicating the nature of the malady. There may be, indeed, 
no symptom referable to the kidneys. A patient dies from a cerebral 
haemorrhage, and after death granular and contracted kidneys are 
found. Another has convulsive seizures, partial or general ; the urine 
is then examined, and albumin is found in it. Another has headaches, 
his nose bleeds, and he suffers from indigestion, acidity, and flatulence,! 
to which his other troubles are referred. Another passes water more 
frequently than seems natural, gets out of bed frequently at night, and 
seeks relief for these symptoms. Another suffers from attacks of 
difficult breathing — asthmatic they seem — or he gets out of breath on 
ascending the stairs or making any considerable exertion ; he has also 
attacks of palpitation and a stridulous cough, and finds that he must 
elevate his head and chest to lie with any comfort at night. And still 
another has vertigo, headache, and disorders of vision, which come 
on without apparent cause. The solution of the problem is at once 



INTERSTITIAL NEPHRITIS. 



531 



afforded by an examination of the urine and tlie discovery of albumin. 
Of all these initial symptoms, frequent micturition, especially at night, 
is the most usual. The urine in typical cases is pale, of low specific 
gravity, and is large in quantity. The color is faintly yellow, or it is 
colorless, of very feeble acid reaction or neutral, and the specific gravity 
falls to 1003 to 1010. While the daily quantity passed by a healthy 
adult is about forty ounces, in this disease the urinary discharges 
amount in twenty-four hours to a gallon or more. It is an ill-omen 
when the urinary discharge falls off considerably, for this indicates 
still greater damage to the kidneys, and bodes the onset of uraemia. 
The urine, as a rule, contains more or less albumin, but it may be ab- 
sent for days together, and indeed may be absent for much of the 
time throughout the disease. Hence frequent examinations must be 
made, and at longer intervals, in doubtful cases. The amount of albu- 
min discharged is not large at any time, and in the beginning of the 
morbid change in the kidney may be very small, so as to produce but a 
faint cloudiness, and requiring the utmost nicety of observation to de- 
tect it. The quantity of albumin is affected by diet, mode of life, and 
by the amount of the urinary discharge. The solid constituents of 
the urine, especially the urea, are much reduced ; uric acid is also 
present in very small quantity, the saline constituents are equally light, 
and the phosphoric acid is especially very much below the normal. 
Hence the urine appears clear, like water, and deposits little sediment. 
There may be seen some octahedral crystals of oxalate of lime, an oc- 
casional epithelial cell, and hyaline casts. The last-mentioned con- 
stituent in the sediment is most important. The casts are few in num- 
ber, and hence the sediment should be collected from a considerable 
quantity of urine. They are pale transparent, their outlines not easily 
discerned, and without structure, except an occasional adherent gran- 
ule or fat-globule. These pale hyaline casts must be distinguished 
from the pale yellow and highly refracting casts which appear in the 
urine in parenchymatous nephritis. 

Sufficient facts have now been accumulated to render it certain that 
there is a form of chronic interstitial nephritis without the presence 
of albumin in the urine. All the other symptoms are, however, quite 
distinct : the copious flow of pale, watery urine of low specific gravity, 
the high tension of the vessels, the hypertrophied arterioles, the en- 
larged heart, the disorders of vision, retinal changes, the headache and 
other nervous phenomena, the neuroses of the respiratory organs, tjie 
disorders of digestion, the failure of nutrition, and the general decline 
in health and strength — indeed, all the characteristic symptoms, except 
the presence of albumin, are encountered in full severity. 

At first, in this disease, the appetite and digestion are good, and 
the nutrition of the body continues unimpaired. Thirst is an early 
symptom. More fluid is taken at meals, and at other times a quantity 
of water, which seems to the patient to pass through the body without 



532 



DISEASES OF THE KIDXEY. 



a halt. Presently, distress after eating, even epigastric pain, flatulence, 
and irregularity in the stools, are experienced. Acidity, pyrosis, de- 
pressing nausea, with headache, come, as the case progresses, to be very 
constant symptoms. The body-weight declines, the skin becomes dry, 
scurfy, and of a dead yellowish- white or fawn color, and the hair ap- 
pears dry and lifeless. The strength fails, and the breathing becomes 
labored on making any exertion. This is due partly to the losses of 
material and partly to the changes occurring in the heart. The left 
cavities undergo hypertrophy, and the arterioles throughout the body 
are in a state of abnormally high tension, owing to hypertrophy of 
their muscular layer ; hence the radial pulse exhibits an exalted tension 
and force. Much discussion has occurred as to the existence of this 
thickening of the muscular fibers of the tunica media, and as to the 
causes, but the fact seems now firmly established. The obstacle to the 
circulation produced by the abnormal tension in the arterioles is the 
chief if not the only factor in causing hypertrophy of the left ven- 
tricle. Toward the end, however, a change takes place in the hyper- 
trophied muscle ; it undergoes fatty degeneration ; then the cardiac 
movements become weak, the sounds indistinct, and the circulation 
feeble. In this form of kidney-disease there is usually no dropsy. It 
is true, oedema may occur from various complicating conditions, if not 
from the kidney-disease. When urine can no longer be separated from 
the blood by the damaged organs there will be dropsy, but death takes 
place with the phenomena of uraemia. When some lesion of a valve oc- 
curs, especially if of the mitral, oedema will appear in the ankles and 
face. Pleural inflammation or hepatic disease may result respectively 
in hydrothorax or ascites. Although the dropsy is never suflicient to 
cause death — is never anything more than an oedema of the face and 
extremities — yet death may be due to a sudden oedema of the lungs. 
When the case is approaching its termination, the symptoms of uraemia 
develop. The nausea which had existed, before, with occasional vomit- 
ing, increases, becomes incessant, and the vomiting is violent and un- 
controllable. The vomiting is not necessarily excited by the presence 
of food ; it occurs when the stomach is empty, in the early morning ; 
and after severe and protracted retching only a little mucus, with a 
quantity of watery fluid of low specific gravity and very feeble acidity, 
comes up. Diarrhoea also now gradually increases, and toward the 
end becomes uncontrollable, the stools being thin, abundant, and fre- 
quent. At last the evacuations consist of a watery fluid, with some 
mucus, and very little fecal matter, and occur involuntarily. The vom- 
iting and purging are largely vicarious of the urinary secretion, which 
contains less and less solid matter. The profuse discharges are very 
exhausting, and consequently serve to develop the symptoms proper to 
uraemia. There is, now, an increasing headache ; much vertigo is ex- 
perienced ; hebetude of mind and a soporose state came on, so that 
when his attention is withdrawn from persons and things the patient 



I 



INTERSTITIAL NEPHRITIS. 



533 



falls asleep in his chair, but sleep at night is disturbed by vivid dreams, 
and there are much muscular twitching, jerking, and heavy, irregular 
breathing. Unsymmetrical convulsive movements, jactitations of indi- 
vidual muscles and groups of muscles, of the face or extremities, and 
general convulsions, occur as the case approaches the end. The patient 
when fully aroused may still be entirely conscious, but he soon lapses 
into stupor when left to himself ; there may be maniacal delirium 
and violent struggling, or unconsciousness between the convulsive 
seizures. An early symptom in many cases of interstitial nephritis is 
amblyopia, double vision, hemiopia, and other derangements of vision. 
As has been pointed out, these symptoms may be the first to attract 
attention, so that the diagnosis is made by the oculist. When the ex- 
amination is made by the ophthalmoscope at an early period, the optic 
disks are found to be swollen ; the veins are enlarged and tortuous, 
while the arteries are rather shrunken. Whitish spots appear on the 
retina, of various sizes, and hsemorrhagic extravasations occur along 
the vessels, but both chiefly about the disks and in the neighborhood 
of the macula lutea. Both eyes are affected, but in varying degrees.* 
While these obvious changes occur during the course of the disease, 
and are permanent, there are fugitive attacks in which vision may be 
lost without any retinal changes. Just as there may be muscular 
twitchings, and even convulsions, without any permament lesions, so 
there may be entire loss of vision without any alterations of the retina. 

Course, Duration, and Termination. — Interstitial nephritis is a very 
chronic malady. There is a long period (often several years) from 
the beginning of frequent micturition to the occurrence of impaired 
functions elsewhere. In those cases marked, as has been pointed out, 
by violent initial symptoms, the disease in the kidneys has proceeded 
silently, and, interfering with no function, has caused no disturbance 
until the sudden outbreak. It sometimes happens that a man falls in 
the street, is violently convulsed, and dies in a few hours comatose, 
the real lesion in the kidney having gone on unobserved for months 
and years, it may be. The duration of the disease can not, therefore, 
be definitely expressed. The termination is most usually with urcemia 
— convulsions, coma, and death. The changes in the vessels and the 
hypertrophy of the heart are the causes of cerebral haemorrhage with 
which many cases end. The excrementitious matters circulating in 
the blood give rise to inflammations of the serous membranes, notably 
pericarditis and endocarditis, which prove fatal. Death may be caused 
by h£emorrhages from the mucous surfaces, or from the exhaustion 
caused by violent vomiting and purging. 

Diagnosis. — The recognition of this disease, when the existence of 
albuminuria has been ascertained, can never be difficult. The large 
quantity of urine, the absence of color, the low specific gravity, the 

* " On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the 
Kidneys," Dr. T. Clifford Allbutt, chapter vii, London : Macmillan & Co. 



534 



DISEASES OF THE KIDXEY. 



small amount of albumin, the hyaline casts, the hypertrophied heart 
and arterioles, are to be compared with the small quantity of urine, 
the high color, the high specific gravity, the immense quantity of albu- 
min and granular casts, the rapid, large, and general accumulation of 
fluid. These prominent features from the clinical standpoint readily 
separate interstitial and parenchymatous nephritis. Pathologically, 
the small, tough, granular kidney and the large, soft, pale, and smooth 
kidney are perfectly distinct. 

Treatment. — As interstitial nephritis is an incurable disorder when 
the proper secreting structure of the organ is destroyed, it is impor- 
tant to arrest the initial changes, if we possess the means of so doing. 
Those cases arising from syphilitic infection, or from plumbic or other 
metallic poisoning, offer the best prospect of cure, if the proper reme- 
dies are applied. It is in the eases arising from these causes, probably, 
that such good results are obtained by the persistent use of full doses 
of the iodide of potassium. The author has observed several cases in 
which the iodides seemed to arrest the disease permanently, and others 
in which the corrosive chloride, administered in small quantity (one 
twentieth of a grain) for a lengthened period, effected cures under 
apparently very unpromising circumstances. Better results even, the 
author believes, are procured from the careful and persistent adminis- 
tration of the chloride of gold and sodium. Very unpromising cases 
have, apparentl}^ yielded to this remedy. It is usually given in pill, 
TF sV grain being given three times a day persistently. Similar 
therapeutical properties are possessed by arsenic. In sclerosis of the 
liver, as well as in that of the kidney, we find that arsenic exercises a 
favorable influence in retarding the changes. This remedy is all the 
more desirable since it has, in small doses, a sedative effect on the 
stomach, and promotes appetite and digestion. These remedies, in- 
tended to arrest the hyperplasia of the connective tissue, should be 
prescribed with a definite relation to the presumed cause — iodide of 
potassium and bichloride of mercury, in those with a syphilitic history ; 
iodide of potassium, in those poisoned by lead ; and chloride of gold 
and arsenic, in those cases of unknown origin. When there are much 
acidity, flatulence, and pain after food, mineral acids, especially the 
nitric, taken before meals render important service. Doubtless the 
uric-acid diathesis is a very influential factor in the development of the 
disease, and hence those remedies which lessen its formation are de- 
serving of high consideration. The utility of the mineral acids con- 
sists in preventing the acid fermentation of the food and in promoting 
digestion, so that the nitrogenous constituents are better prepared for 
assimilation. For the anaemia present, iron is generally prescribed, 
but the effects are usually rather disappointing. The most useful 
chalybeate is the tincture ferri acetata, which is also formed extempo- 
raneously in Basham's mixture, composed of tinct. ferri chloridi, liquor 
ammonise acetatis, and acetic acid. If iron is given freely and for a 



INTERSTITIAL NEPHRITIS. 



535 



long time, headache and a disordered stomach will require its discon- 
tinuance ; nevertheless, the occasional and careful use of iron is bene- 
ficial. Kemarkable results have been achieved by the use of nitro-gly- 
cerine. It lessens the high tension of the vessels, relieves the pain in 
the head, and removes many of the disagreeable subjective sensations. 
By dilating the arterioles this remedy probably, also, improves the nutri- 
tion of the kidneys. The author has usually given this remedy in the 
form of the one per cent, solution, beginning with one drop and increas- 
ing the dose until its physiological effects are experienced. The dose in 
this form of the remedy is more easily regulated. The chloride of gold 
and sodium may be administered coincidently. When the symptoms of 
uraemia come on, the case requires most careful handling. If the stom- 
ach and intestines are yet capable of good work, the treatment may be 
more direct and efficient ; but if the severe, even uncontrollable vomit- 
ing and purging occur, so often present as a part of the uraemia, the 
difficulties of the management are greatly enhanced. In the former 
case, active purgatives, as elaterium, croton-oil, and compound jalap 
powder, procure elimination through the intestinal canal, and are of 
signal service. In the latter case, the important results derived from 
purgatives are precluded. Diaphoretics, as the vapor or hot-air bath 
and the injection subcutaneously of pilocarpine, are the most powerful 
means of relief. Purgatives and the vapor-bath, or pilocarpine, will 
in those cases of acute exacerbation in the renal trouble, when the 
patient is yet in good condition, relieve the symptoms remarkably, and 
subsequently there may be a long period of tolerable health. The con- 
vulsive and nervous phenomena of uraemia are best remedied by the 
means for procuring elimination, but, if the symptoms are urgent, the 
inhalation of amyl nitrite, chloroform, and ether may be necessary. The 
hypodermatic injection of morphine in large doses has been shown by 
Loomis, of New York, to have a remarkable influence on the convul- 
sions of uraemia ; but chloral by the stomach or rectum may be better. 

The nutrition of the patient is of the first consequence. The diet 
should be simple, and consist of milk, eggs, a little fresh meat (once a 
day), and fruits, if diarrhoea does not exist. The best results have been 
obtained from an exclusive milk-diet ; as this becomes irksome, intoler- 
able even, the plan of diet just suggested is best. Malt liquors, spirits, 
and wines are highly objectionable, especially the first named. The 
clothing should be warm ; flannel should be worn by day, and the patient 
should sleep between blankets. Whenever his means will permit, the pa- 
tient should seek a warm, dry, and uniform climate. Recent observations 
by Drs. Sparks and Bruce in respect to the influence of diet, rest, and ex- 
ercise, on the excretion of albumin, have led to the following results : the 
amount of albumin is much reduced by a milk-diet and non-nitrogenous 
food, and " absolute rest remarkably reduced the amount of albumin." * 
* " Medico-Chirurgical Transactions," 1879, p. 254. 



536 



DISEASES OF THE KIDNEY. 



HEMATURIA— H^MATINURIA—H-^MOGLOBINURIA. 

Definition. — By hoematuria is meant the discharge of blood in the 
urine. It is a symptom rather than a disease, and is discussed in connec- 
tion with maladies of which it is a part. Hcematinuria signifies the pres- 
ence of blood coloring matter in the urine, and is a paroxysmal affection, 
accompanied by constitutional disturbance, and most frequently caused 
by malarial toxaemia. It is also designated hoemoglobinuria. 

Pathogeny. — Sex is an important factor in the pathogeny of this 
affection, males being most freqently (ten to one) the subjects of it. 
Youth and adult life are the periods during which it appears, and 
after fifty it is very uncommon. The chief cause of hjematinuria 
is malarial poisoning, and hence the disease is encountered within 
the malarial zone. In the Southern States, especially in Alabama, it 
is becoming more frequent, and the severe or malignant form is now 
comparatively common. As a rule, it is irregularly intermittent, but 
there are many exceptions to the rule in that the morbid manifesta- 
tions are remittent or continuous. 

Although regarded generally as a modification of the blood, there 
are recent observations which tend to prove that a form of nephritis 
is also necessary.* The essential condition is a disorganization of the 
blood-corpuscles, separation of the ha^matin, and such a change in the 
walls of the capillaries as to permit transudation of these elements. 

Symptoms. — The attacks of haematinuria are severe in proportion 
to the local activity of the malarial poison. Within the tropics the 
maximum violence of all the symptoms is reached. It is usual to 
describe two forms — the mild and the severe — but it is quite certain 
that between the extremes there are numerous gradations in the sever- 
ity of the manifestations dependent on the climatic conditions. The 
persons attacked, boys or men usually, have been exposed to malarial 
infection if not attacked with malarial fever. In the mildest cases the 
onset of the hiematinuria is announced by the sudden appearance of 
bloody-looking urine, some lassitude, chilliness or coldness of the 
hands and feet, muscular pains and weariness, yawning, blue lips and 
finger-nails, followed by a reaction stage, fever, terminating in a sweat 
of greater or less severity. With the subsidence of these symptoms, 
the urine changes in appearance, the blood coloring matter disappears 
and the normal is restored, and the general health may be entirely re- 
covered. In the severest form the chill approaches the congestive in 
character ; there is profound depression of the powers of life ; vomit- 
ing occurs ; the urine becomes deeply colored, the skin yellow, and the 
fever high, remittent in type, or passing into continued. 

The most characteristic feature in every way, and that which 

* Ponfick, Yirchow's "Arcliiv," vol. Ixxxviii, p. 4*76. Also, Lebedeff. Ibid., vol. 
xci, p. 267. 



HEMATURIA. 



637 



gives it most importance, is the appearance of the urine. The color 
varies from a slight reddish tinge to a deep port- wine, and the deposit 
which collects on standing is composed of the debris of disintegrated 
blood-corpuscles, epithelium of the tubules, amorphous urates, and 
sometimes brownish casts of a hyaline character, or made up of dis- 
integrating blood-globules, or pigment-matter. Albumin is present 
in considerable quantity, and blood-disks sometimes, but usually the 
bloody appearance of the urine is due to the blood-pigment in a gran- 
ular form or dissolved, and the reaction is decidedly acid, rarely alka- 
line. When the paroxysm is over, the abnormal coloration lessens, then 
ceases, the albumin disappears, and in a few hours the urine becomes 
healthy. When the next paroxysm comes on the same phenomena 
occur. . The malarial poison must then, directly, or through the 
agency of some substance formed in the intestinal canal, act on the 
blood-corpuscles, extract the haemoglobin which is dissolved in the 
serum and eliminated by the kidneys, or which destroys the corpuscles 
in the liver, spleen, and kidneys. When the blood is examined, the 
white blood-disks are found to be increased in number, and the red 
are paler in tint, and exhibit no tendency to form the characteristic 
rouleaux, or the color disappears entirely, and the disks are changed 
in shape. 

Urticaria often manifests itself, especially on parts exposed to cold, 
and the skin has either an icterode hue or is deeply jaundiced, which 
passes off after the systemic disturbance is entirely ended. 

Course, Duration and Termination. — As seen in this country, hasma- 
tinuria is a distinctly periodical affection ; occurring with considera- 
ble regularity, and accompanied by the usual systemic disturbances 
of a malarial fever. IsTot all the cases are regularly intermittent and 
paroxysmal ; some of them are remittent ; a few continued in type. 
The intermittent cases may be free from fever, the urinary symptoms 
apparently taking the place of the usual chill, fever, and sweat. It has 
no fixed period of duration, and may last indefinitely, but much de- 
pends on the role of malaria in its production, and the appropriate use 
of quinine. In the author's experience it has a decided tendency to 
recur again and again, after it has been entirely relieved, and the nor- 
mal condition of the urine and the blood restored. Chronic nephritis 
is an outcome of some cases, and intercurrent diseases, especially 
pneumonia, are apt to occur. 

Diagnosis. — Haematinuria is distinguished from hiematuria, with 
which, necessarily, it is most frequently confounded, by the presence 
of the blood-pigment without the blood-globules, at least in their nor- 
mal form, by its periodical character, by the absence of the local lesions 
producing the latter, and by the presence of casts in the urine. Can- 
cer of the kidney is accompanied by haematuria, but in that case blood 
is present, the discharge of blood is not periodical, and fever is want- 
ing. Cancer is accompanied by a marked cachexia, by decline in 



538 



DISEASES OF THE KIDNEY. 



health and strength before the local symptoms assume importance ; 
hsematmuria as a rule does not impair the vital forces to any consid- 
erable extent, except during the paroxysms, and after these are ended 
a prompt return to the normal occurs. 

Treatment. — The most important remedy is quinine, and that it 
must be given in large doses is the conclusion of the physicians of the 
South, who have the largest experience,* and is the author's judgment, 
after considerable observation of the disease. The patient must be 
cinchonized, in anticipation of the seizure, whenever the time for re- 
currence can be fixed on, and attention must be given to the " sep- 
tenary periods," so called, that the outbreaks which may occur at cer- 
tain times, following the law of evolution of the malarial poison, may 
be prevented. Dr. Narcom advocates the use of morphine, and his view 
is confirmed by others. It may be given with the quinine, or admin- 
istered hypodermatically at the onset of a paroxysm. According to 
Ilalfe,f arsenic is a remedy of great value, not so much for the imme- 
diate relief of the paroxysms as for the improvement of the patient's 
condition and the prevention of subsequent seizures. He administers 
it persistently in the intervals. A combination of quinine, arsenic, 
and ergot, given regularly, for several months if need be, has a re- 
markable effect in bringing about improvement and cure.]; Such a 
combination should be administered after the impression made by 
large doses of quinine has been effected. 



THE AMYLOm DISEASE OF THE KIDNEYS. 

Definition. — By the term amyloid disease is meant an affection 
characterized by the deposit of amyloid matter. As it occurs in the 
kidneys, this disease is known as lardaceous kidney, waxy Mdney, 
because of the supposed resemblance to lard and wax respectively. 
By Dickinson the disease is distinguished by the title " depurative 
infiltration." 

Causes. — The chief cause is suppuration, especially protracted sup- 
puration of or connected with the cancellous structure of bones, or 
ulcerations affecting the skin and mucous membrane. It is neces- 
sary that the suppuration be profuse and protracted, but it is not 
necessary that it occur in bone only. But suppuration alone is not 
sufficient to cause the amyloid deposit. There must be a peculiarity 
of constitution precedent, for, of all exposed to this destructive malady 

* Dr. Thomas J. Turpin, of Forldand, Alabama, *'The Treatment of Haemorrhagic Ma- 
larial Fever " (pamphlet) ; Dr. W. A. B. Narcom, " Transactions of the North Carolina 
Medical Association " for 1874. 

f " A Practical Treatise on Diseases of the Kidneys." London, 1885, p. 552. 

X B Quininge sulph., 3j; ext. ergotfe (Squibb), 3j ; ferri arseniat., gr. iij. M. Ft 
pil. no. XX. Sig. : One pill three times a day. 



AMYLOID KIDXEY. 



539 



by suppuration, but a small number actually are affected by amyloid 
change. It is more apt to occur in those under the influence of chronic 
malarial poisoning, but more influential diathetic states are those of 
syphilis, scrofula, tuberculosis, and cancer — especially cancer.* It is 
impossible to indicate in the present state of knowledge the relation 
of these cachexijB to amyloid disease, but it seems pretty clear that 
more or less protracted suppuration coincided with the cachexia. 
According to Bartels, ulcerations of the intestines are more certain 
than ulcerations of any other mucous membrane to induce amyloid 
disease ; and, further, that the suppurating center must have communi- 
cation with air to possess this peculiar property. The amyloid depos- 
its are not limited to one organ, but occur in the liver, spleen, intesti- 
nal canal, the supra-renal bodies, the lymphatic glands, the thyroid 
gland, and the kidneys. 

Pathological Anatomy. — The term amyloid^ or starch-like, was 
originally proposed by Yirchow, because of the reaction under iodine, 
and the characteristic structure remotely resembling starch. The 
theory of Dickinson that this substance is fibrin deprived of its 
alkali, which has been eliminated from the body in the pus, has been 
completely disproved by the elaborate investigations of Mr. George 
Budd.f " The cells of an organ affected may be seen to become 
gradually distended with a translucent deposit, and soon an accumu- 
lation of a similar deposit takes place in the intercellular spaces also." 
There is present in the blood in the normal a considerable quantity of a 
substance, named by Seegen " dystropodextrin " — " a substance which 
agrees with lardacein (amyljoid material) in its most specific charac- 
teristic." To account for lardaceous disease, then, it is only necessary 
to suppose that this dystropodextrin becomes insoluble, and is precipi- 
tated and deposited in the tissues. This substance reacts to iodine, 
just as the amyloid matter, and agrees with it in all other particulars, 
so that this theory is more plausible than any heretofore proposed. 
When the lardacein is deposited in the kidneys to a consider- 
able extent, the organs are larger and heavier than normal, and are 
also very firm in texture. The capsule, which is very thin, is easily 
detached, and the surface of the kidney is pale, gray, or whitish, and 
has a glistening, even a polished, appearance. The cortical part is 
broad, but pale and anaemic, while the cones are dark and congested. 
On microscopic examination, the change that has taken place in the 
ororan is found to have occurred alono^ the renal vessels and in the vas- 
cular tufts of the glomeruli, at first at isolated points, and subsequent- 
ly along the whole extent of these vessels. As the morbid process 

* " Transactions of the Pathological Society " of London, vol. xxx, p. 511 ; paper by 
Dr. Dickinson, and discussion. 

f London " Lancet," February 2S and March 27, 18S0 ; " Amyloid Degeneration," by 
George Budd, Jr. 



DISEASES OF THE KIDXEY. 



extends, the afferent and efferent vessels, the vasa recta, and ulti- 
mately the renal epithelium and even casts, still contained within the 
tubes, are seen to be embraced in the degeneration or deposition. If 
a thin section of the kidney is laid on a white plate after being brushed 
over with the iodine solution (iodine and iodide of potassium), the 
branching lines and points of reddish-brown stand out prominently 
beside the pale yellow of the healthy tissues.* Besides the kidneys, 
other organs of the body undergo the same change, but the kidneys 
may be affected alone. The supra-renal capsules, the liver, spleen, the 
intestinal canal, etc., are similarly affected. When an organ is thus 
infiltrated by this new material, its proper structure undergoes an 
atrophic degeneration by pressure. With the amyloid change may be 
associated interstitial or parenchymatous nephritis, especially the lat- 
ter. It is more proper to say that during the progress of interstitial 
nephritis the amyloid degeneration comes on ; hence the lardaceous or 
amyloid kidney may be more or less granular and contracted, instead 
of being enlarged and smooth. With lardaceous kidney are associated 
chronic ulceration of the lungs, and suppurating cavities, ulcerations 
of the intestines, diseases of bones and joints, syphilitic lesions of the 
mucous membrane, external integument, and scrofulous abscesses. 

Symptoms. — As amyloid disease of the kidney arises during the 
course of some chronic wasting malady, its onset is necessarily ob- 
scured by the complexus of symptoms already prominent. There is, 
of course, a marked degree of anaemia produced by prolonged suppu- 
ration, and by amyloid changes in other organs besides the kidney. 
The urine is, as a rule, increased in amount and may be considerably so, 
especially in those cases complicated by interstitial nephritis, or it may 
be considerably diminished in quantity, when there coexists parenchym- 
atous nephritis. But in genuine amyloid kidney the urine is increased, 
is pale, watery, and of very low specific gravity — 1002 not unfrequent- 
ly— and usually under 1006. When associated with parenchymatous 
nephritis the specific gravity may rise to 1030, or when, as may hap- 
pen, the quantity passed is very low. The amount of urea and other 
solid constituents is much reduced when the quantity is great, and 
greater when the quantity of urine is small. The amount of urea ex- 
creted depends on two factors : on the functional activity of the liver 
and the extent of disease in the kidneys. Albumin is always present. 
At times, during the first implication of the kidneys in the morbid pro- 
cess, there may be none, and when present the quantity is sufficient to 
impart a faint cloudiness merely, but it becomes permanent as a con- 
stituent of the urine during the height of the disease, unless just at the 
close, when it may disappear again. The urine contains so little else 

* Safranine, an aniline product, is said to be an admirable test for amyloid matter. 
Sections are immersed in a very dilute watery solution. Tke amyloid matter is stained 
orange-yellow ; the rest of the tissue, rose. 



AMYLOID KIDNEY. 



541 



than water that the sediment is very small in amount, and hence it re- 
quires a good deal of urine to collect even a few casts. Only the hyaline 
casts are proper to this disease ; they are perfectly transparent, homo- 
geneous, and slender, so that they are seen only by careful management 
of the light. Large granular casts, blood-corpuscles, and renal epithe- 
lium may be present in considerable quantity when parenchymatous 




Fig. 41. — A Large Hyaline Cast without, and Two with Epithelium. (Beale.) 



nephritis is a complication. The casts may present a faintly yellow 
and highly refracting appearance when attacked by the amyloid change 
or composed of the amyloid material. 

More or less oedema is always present, but general dropsy is infre- 
quent. The oedema is found in the lower extremities, and ascites is 
usually present, and disproportionate to the quantity of fluid elsewhere. 
This is doubtless due to the implication of the liver in the general 
morbid process, and to the swelling of the lymphatics in the hilus of 
the liver, compressing the vena porta. With the progress of the dis- 
ease, there are necessarily increasing weakness and anasmia, a pecu- 
liar earthy or fawn color of the skin, and pigmentation of the eyelids. 
The exhaustion of the vital forces is greatly hastened by the occur- 
rence of a profuse, watery, and uncontrollable diarrhoea. Vomiting also 
occasionally takes place, but not nearly with the frequency and persist- 
ence of the diarrhoea. 

Course, Duration, and Termination.— Amyloid kidney is an essen- 
tially chronic malady, but its fortunes partake of the changes and 
progress of the associated malady. Commencing insidiously, its pres- 
ence is recognized only when an increasing urinary discharge calls 
attention to the state of the kidneys. The duration of the disease is 
largely determined by the suppurating malady causing it ; but, when the 



542 



DISEASES OF THE KIDNEY. 



amyloid change is clearly begun, the case usually terminates in death 
in a few months, but may extend to years. Uraemia, as manifest in 
vomiting, purging, amaurosis, partial and general convulsions, etc., 
does not occur in amyloid disease, unless the contracting kidney also 
develops, or there is a sudden appearance of parenchymatous nephritis. 
Death by cerebral haemorrhage is also rare. Hypertrophy of the 
heart and of the arterioles does not take place in this form of kidney- 
disease. The termination is often by some acute inflammation, as pneu- 
monia, pleuritis, or purulent peritonitis, etc. The duration will neces- 
sarily be much influenced by the occurrence of such inflammation. 
Many of the cases terminate by exhaustion, the bodily forces being 
worn out by the protracted suppuration and the loss of albumin, but 
especially by the profuse diarrhoea. The termination may, then, be 
due in most cases to lesions of other organs. The question of recovery 
is largely that of the associated diseases. The data do not yet exist 
for deciding on the possibility of an arrest of the amyloid change in 
the kidneys, or the regression of deposits already made, but it is ex- 
tremely doubtful whether a genuine case ever terminates in recovery. 
In a reported case of recovery there must ever remain a doubt respect- 
ing the accuracy of the diagnosis. 

Diagnosis. — Amyloid kidney is to be distinguished from paren- 
chymatous nephritis and interstitial nephritis. The history of the case 
is here highly important, especially the constant relation of suppura- 
tion to lardaceous degeneration. In parenchymatous nephritis the 
urine is scanty, high-colored, of high specific gravity, and deposits an 
abundant sediment, containing urates, granular casts, tubular epithe- 
lium, and red-blood globules ; in amyloid kidney the urine is abun- 
dant, pale, of low specific gravity, deposits very little sediment, con- 
taining a few hyaline casts and occasional waxy casts, but no blood- 
corpuscles. In parenchymatous nephritis, dropsy forms quickly and 
is extensive ; in amyloid kidney, the effusion is slight and confined to 
the lower extremities and to the peritoneal cavity. Amyloid kidney 
is distinguished from chronic interstitial nephritis by its history and 
association with suppuration in some form, and with the evidences of 
the same change in the liver, spleen, and intestinal canal. In chronic 
interstitial nephritis the symptoms of uraemia are very pronounced at 
some period ; in amyloid kidney these symptoms very rarely occur at 
any period. 

Treatment. — As when the amyloid deposits have taken place it 
seems doubtful if their removal can be effected, it is highly important 
to stop all sources of suppuration, and thus prevent the deposition of 
the altered fibrin. Attention should be directed at once to the cure 
of suppuration. As syphilis and the suppuration connected with it are 
a fruitful source of mischief in this direction, this malady should be 
efiiciently treated and cured, and all cases presenting a syphilitic his- 
tory should be given a thorough course of the iodide of potassium. 



PYELITIS. 



543 



Dickinson, influenced by his theoretical notions, advises the internal 
use of the potash and soda salts, supplying artificially the alkali which 
is carried off in the pus, while the fibrin is deprived of it. He at the 
same time enjoins the free use of eggs and milk, to supply the material 
lost in the urine. A combination of the chloride of gold and sodium 
(tV S^') bichloride of mercury (Jg- gr.), persistently administered, 
accomplishes more than any other remedies. Iron, cod-liver oil, and a 
generous diet are demanded by the condition of feebleness and anaemia. 
The exhausting diarrhoea resists all means of treatment, but the most 
efficient remedy, according to the author's experience, is Fowler's solu- 
tion and opium tincture — three drops of the former and five to ten of 
the latter, three or four times a day. 

PYELITIS AND PYELONEPHRITIS. 

Definition. — Pyelitis means an inflammation of the pelvis of the kid- 
ney ; pyelonephritis includes pyelitis and a consecutive or simultaneous 
suppurative inflammation of the kidneys. They are here considered 
together to avoid repetition, and because of their frequent association. 

Causes. — Probably the most frequent cause of pyelitis is the exten- 
sion of a morbid process from the bladder to the pelvis of the kidney, 
by the ureter. Catarrh of the bladder is lighted up by decomposition 
of the urine, consequent on its retention. Whenever an obstacle exists 
to the discharge of urine from the bladder, the decomposition ensues, 
the urine becomes ammoniacal, and the mucous membrane the seat of 
an active catarrhal process. Stricture of the urethra, enlarged prostate, 
the pressure of the retroverted uterus, pregnant uterus, or of a pelvic 
tumor, etc., act by hindering the urinary discharge. An inflammation 
of the mucous membrane of the bladder, due to gonorrhoea or other 
causes, will have the same effect by causing fermentation of the urine. 
A renal calculus, or other foreign body, present in the pelvis of the 
kidney, will produce catarrh directly by irritating the mucous mem- 
brane. Decomposition of the urine and catarrh extending to the pelvis 
of the kidney are produced by paraplegia : the bladder being para- 
lyzed, the urine is retained and undergoes putrefactive fermentation. 
Diuretics of the stimulant kind, as copaiba, turpentine, and cantharides, 
irritate the mucous membrane of the pelvis of the kidney in passing 
through these organs. Whenever the urine decomposes, vibrios and 
bacteria appear in it in immense numbers ; the urea is decomposed and 
converted into the carbonate of ammonia ; the ammoniaco-magnesian 
phosphate crystals are formed in great quantity, and much phosphate 
of lime is separated by the inflamed mucous membrane. Pyelitis 
occurs as a complication in various infective maladies — in pysemia, 
puerperal fever, the exanthemata, etc., and may result from the exten- 
sion of a neighboring inflammation. 

Pathological Anatomy.-— The changes consist in the ordinary catar- 



544 



DISEASES OF THE KIDNEY. 



rlial process, the mucosa and the submucosa becoming very much thick- 
ened in old cases, the vessels varicose, and the epithelium much changed 
by the proliferation of its cells, etc. If the morbid process began in 
the bladder, the evidence will be plain, and the ureters may or may not 
be affected by the same changes. If the pyelitis has existed for some 
time, the kidneys will be seen to be in a process of suppuration — one 
or both. The organ is more or less enlarged, is deeply congested and 
reddish, except certain spots which present a yellowish-white color, are 
wedge-shaped, and extend through the cortex to the apex of the cone. 
On section these patches present here and there points of suppura- 
tion, are swollen, and the capsule is more or less firmly adherent to 
them. Suppuration occurs soon all along the extent of these patches 
between the tubules. Several of these suppurating patches uniting, 
considerable abscesses form ; the kidney elements are disassociated, 
broken up, and disappear ; and from the cones the suppuration pro- 
ceeding destroys the cortical part, and ultimately nothing remains but 
a bag of pus having irregular walls marked by septa, remains of caly- 
ces. It seems well established that the suppurative inflammation in 
the kidneys is set up by the presence of bacterian colonies which have 
migrated from the inflamed bladder. With high powers the bacteria 
are seen arranged in parallel lines within the tubules. They appear as 
minute, globular, highly refracting granules. After a time the same 
bodies are seen in the interstices with pus-corpuscles. The epithelium 
of the tubules is at first cloudy, granular from fatty degeneration, but 
is soon destroyed, the whole tube being filled with the branching fila- 
ments and spores. According to Klebs (Ebstein), the inflammation 
proceeding to suppuration is excited by the bacteria. 

Symptoms. — The pyelitis or pyelonephritis usually encountered is 
associated with chronic cystitis, ammoniacal urine, and the systemic 
state produced thereby. When due to the presence of a calculus in 
the pelvis of a kidney, the symptoms are different in some respects ; 
hence the consideration of this form is properly postponed to the sec- 
tion devoted to this topic. In the form of pyelitis now under consid- 
eration, there is usually more or less irritability of the bladder, and the 
urine is somewhat more abundant than normal. The urine is neutral 
or alkaline in reaction, milky in appearance when voided, and deposits 
a copious sediment, whitish or faintly yellowish-white in color. The 
upper layer of the sediment is more distinctly whitish, lighter, and 
easily disturbed with a little agitation, whereas the bottom layer is 
heavier, firmer, and unites in an homogeneous mass which sticks closely 
to the vessel, and when dislodged rolls out in a tenacious, gelatinous 
mass. There is some albumin present, but not more than is proper to 
pus. On microscopic examination there are present mucus and pus- 
corpuscles, chiefly large crystals of ammoniaco-magnesian phosphate, 
and by no means frequently epithelial cells from the pelvis of the kid- 



PYELITIS. 



545 



neys. In the form of pyelitis arising from decomposing urine in the 
bladder, it is difficult to find the morphotic elements belonging to 
the kidney. Besides the corpuscular and crystalline forms above men- 
tioned, the urine contains numberless bacteria. There is more or less 




Fig. 42. — Various Forms seen in Pyelitis. 



uneasiness felt posteriorly just under the false ribs and extending 
downward along the course of the ureters, and the usual distress aris- 
ing from the bladder under these circumstances. The strength de- 
clines, the body loses flesh, and there is more or less fever, increasing 
toward evening and with a morning remission. In some cases, when 
pyelonephritis is developed and suppuration is going on in the kid- 
ney, the fever has a distinct typhoid type, and has been mistaken for 
typhoid ; for the cerebral disturbance — low-muttering delirium — siib- 
sultus tendinum^ and stupor, due to uraemia, come on with septicsemic 
fever, diarrhoea, and exhaustion, due to suppuration. In still a third 
group the symptoms are those of pyaemia. Chills occur at irregular 
intervals, followed by very high temperature, the thermometer indi- 
cating 104°, 105°, or 106° Fahr., and then a profuse sweat. The face 
has an earthy hue, the countenance is anxious, and the features are re- 
tracted and pinched. The exhaustion is extreme, the pulse feeble 
and rapid. During the febrile exacerbation there is usually more or 
less delirium. A profuse diarrhoea and complete anorexia hasten the 
decline. Secondary abscesses may form in the articulations, or in the 
intermuscular septa, which increase the already rapid tendency down- 
ward. 

Besides the usual form of pyelitis and pyelonephritis associated with 
the various obstacles to the outflow of urine, and with ammoniacal and 
decomposing urine, there are several milder forms. Certain renal irri- 
tants, as cantharides, turpentine, etc., and exposure of the body to cold 
while in a warm and perspiring state, will produce a simple, primary, 
acute pyelitis. There occurs more or less pain in the region of the kid- 
neys, extending downward along the course of the ureters, and there 
may be slight feverishness toward evening. The urine is acid and 
somewhat increased in quantity. It deposits a sediment composed of 
urates, pus, and occasional blood-corpuscles, and epithelium from the 
pelvis of the kidney. Pyelitis also occurs in childbed. Then it begins 
with chili, followed by fever, and pain in the lumbar region. The pain 
may have a very acute character, and, shooting down along the ureters 



546 



DISEASES OF THE KIDNEY. 



into the bladder, seem like nephritic colic. The urine is little changed 
from normal, but it contains some pus and cells of renal epithelium. 

Course, Duration, and Termination.— The simple cases of pyelitis 
terminate in recovery in from one to two weeks. Those occurring in 
childbed, or in the course of typhoid, puerperal, or other fevers, ter- 
minate with the associated malady. Suppurative pyelitis and pye- 
lonephritis have a variable duration, and may continue for months, 
even years. The progress is, of course, more rapid when the kidney is 
suppurating. When ursemic symptoms occur, the duration of the case 
is measured by weeks, and but one termination is possible. 

Diagnosis. — In the most common variety the diagnosis is often mere- 
ly conjectural, for the muco-pus is so abundant that it is extremely dif- 
ficult to find the characteristic forms from the pelvis. When urasmic 
symptoms finally come on, there can be doubt no longer. In the simple 
cases the diagnosis must rest on the association of pain, with altered 
urinary secretion, the epithelium of the pelvis of the kidney being 
present. 

Treatment. — In the simple cases mere dilution of the urine affords 
relief. If the urine is acid, a potash salt — liq. potassii citratis — should 
be administered freely. In the cases of pyelitis associated with ammo- 
niacal urine, benzoic acid is extremely serviceable. Gallic acid, pass- 
ing through the kidneys unchanged, has a local effect of a very useful 
kind. Excellent results have been obtained from the persistent use of 
eucalyptol, or fluid extract of eucalyptus. The oils of turpentine, co- 
paiba, and cubeb have a good effect in changing the character of the 
mucous membrane and limiting the formation of pus ; but they must 
be given in small doses. Quinine has a high degree of utility — to keep 
down the abnormal temperature, to support the powers of life, and to 
check pus-forming. It is important throughout to keep up the strength 
by suitable aliment. 



RENAL CALCULI— NEPHROLITHIASIS. 

Definition. — Renal calculi are concretions formed by precipitation 
of certain substances from the urine about some body or material act- 
ing as a nucleus. 

Causes. — Calculi occur at all ages, and are very frequent in chil-' 
dren before the fifth year, and from five to fifteen. Males are much' 
more liable to them than females. A sedentary life and indulgence 
in a highly nitrogenized diet are circumstances favoring the occurrence 
of the uric-acid diathesis. Certain districts of country seem pecu- 
liarly disposing, the character of the drinking-water being held respon- 
sible, especially the lime present, but this explanation of the fact is 
wholly untenable. A special susceptibility exists in certain families,* 
* London "Lancet," December 5, 1874. 



RENAL CALCULI. 



54Y 



various members of whicli may be attacked, while other families living 
under the same conditions are unaffected. 

Pathogeny. — The researches of Dr. H. Vandyke Carter, Ord,* 
Beale, and others have demonstrated the importance of mucus in de- 
termining the precipitation of the calculous ingredients of the urine. 
Calculi are of all sizes— from microscopic bodies up to a concretion fill- 
ing the pelvis of the kidney. Beale f has shown the importance of 
microscopic calculi present in the urine, as indicating similar bodies of 
larger size in tlie pelvis. In the kidneys there may be an infinitude of 
calculi — from mere grains of sand to concretions of considerable size. 
Uric-acid infarctions, triple phosphate- and carbonate-of-lime infarc- 
tions, are found in the straight tubes of the pyramids in infants, and 
in old men, especially those affected with the gouty diathesis. Cal- 
culi of uric acid are more frequent than any other constituent, for, 
although this substance exists in small quantity, it is very slightly 
soluble. Ord shows that uric acid, crystallizing in the presence of col- 
loids (albumin, mucus, etc.), tends to assume a spheroidal form, and 
Carter that a bit of mucus is the nucleus about which the crystalliza- 
tion takes place. These calculi are made up of concentric layers, and 
may be composed wholly of uric acid, or of alternate layers of uric 
acid and oxalate of lime. Similar modifications are impressed on oxa- 
late of lime, but while they tend to assume the spheriodal form in the 
presence of mucus they also crystallize in octohedra. The uric-acid 
calculi are grayish-red or reddish-brown, smooth, hard, and having a 
specific gravity of 1*5. The pure oxalate-of-lime calculi are very rare, 
are very hard in texture, rough on the exterior, of a dark -brownish 
color. The oxalate of lime with a nucleus of uric acid are much more 
common than the pure oxalate. Calculi of cystine are still more rare 
than those of oxalate of lime ; they are comparatively soft, and have 
a dull-yellow or amber color. Phosphatic, next to uric, are the most 
frequently encountered calculi. They are very light, friable, of a dull 
or grayish-white, or bright white, rough, and sometimes polished. 
The phosphatic deposit, consisting of phosphate of lime and the am- 
moniaco-magnesian phosphate, often forms about a uric-acid calcu- 
lus which has been present for some time. This deposition of the 
phosphates may be expected to take place on a uric-acid calculus 
which has been long present in the pelvis of the kidney, if the urine 
becomes alkaline. The stones may be in one, but occasionally they 
are found in both kidneys. In the cases which have fallen under my 
observation, two thirds were in the left kidney. The results of the 
presence of concretions differ according to their situation : in the 
tubules, as infarctions, they excite inflammation of the kidney ; in 
the pelvis they cause pyelitis. Gouty kidney is a result of the uric- 



* "Lancet," March 13, 1875. 



f Beale on " Urinary Deposits." 



54:8 



DISEASES OF THE KIDNEY. 



acid diathesis, and deposits of this substance take place in the pyra- 
mids and the cortex, parenchymatous and interstitial nephritis de- 
velop, and the organs ultimately become granular. When nephro- 
pyelitis is fully developed, extension of the morbid process to the 
kidney proper takes place. When pyelitis is lighted up, the mucous 
membrane becomes intensely injected, and a quantity of muco-pus, 
proliferating epithelium, and young cells, form a yellowish, rather thick, 
purif orm fluid. If a concretion is not too large, it will be washed down 
into the bladder, with the phenomena of nephritic colic. Successive 
calculi passing, the ureter yields and dilates, and, as these concretions, in 
passing, excite inflammation, the walls of the ureters become thickened. 
An attack of inflammation may close the canal entirely, or a ureter 
may be closed by an impacted calculus. In either case the contents of 
the pelvis accumulate, the proper structure of the kidney undergoes 
atrophy, and after a time only a membranous sac filled with fluid and 
concretions remains. The ichorous contents may ulcerate through, 
form an abscess of large dimensions, w^hich may make its way exter- 
nally, discharging in the lumbar region, or, dissecting downward, may 
point underneath Poupart's ligament, or enter the colon, etc. 

Symptoms. — A calculus may remain in the pelvis of a kidney for a 
long time — during many years — it is probable, without giving rise to 
any disturbance. Usually, very distinct symptoms are occasioned, and 
serious results grow out of them. A calculus causes very violent 
symptoms when washed into the ureter. Usually, an attack of ne- 
phritic colic occurs suddenly. Without any warning, an atrocious pain 
strikes the lumbar region, passes downward along the course of the 
ureter into the groin, and radiates thence upward into the shoulder- 
blade and through the abdomen. Pains occur in the corresponding 
testis, which is retracted close up to the external ring, and more or 
less pain, sometimes very acute pain, is felt in the glans penis. So 
severe is the pain that the most self-controlled person cries out with 
the agony, rolls from side to side, or rushes up and down the room 
seeking for some alleviation in incessant motion. The face is pale and 
torn with agony, the features are pinched, the body is cold and covered 
with a cold sweat. The thigh of the affected side is benumbed, and 
sometimes the whole of the corresponding limb. The patient may 
faint, or pass into unconsciousness with a general convulsion. The 
stomach participates in the disturbance with nausea, or with severe 
vomiting. The bladder is very irritable, and frequent attempts at 
micturition are made, but, with much burning pain and straining, only 
a few drops are passed. The urine is dark, and usually contains blood, 
but it may be perfectly normal, for, as but one ureter is involved at one 
time, the urine from the unaffected kidney may pass without admix- 
ture. The urine may be not only dark and bloody, but it may contain 
pus. There may be complete anuria from blocking of both ureters, 



RENAL CALCULI. 



549 



but usually the calculi do not fit accurately, and some urine escapes 
alongside them. If anuria is the result, and the obstacle is not re- 
moved, death in coma and convulsions is inevitable. The paroxysm, 
after some minutes or hours, usually terminates suddenly by the escape 
of the stone into the bladder. The urine accumulating behind the stone 
forces it onward with increasing agony, until, at last dropping into the 
bladder, the horrible pain ceases, the patient utters a sigh of relief, and 
falling on the bed exhausted is soon fast asleep. The attacks do not 



No. 1. 




Fig. 43.— Various Crystalline Forms. 
No. l.-Uric Acid. 2.-Urate of Soda. 

No. S.-Cystine. No. ^.-Oxalate of Lime. 

Ko. 5.— Dumb-bell Oxalate of Lime. 

always come on abruptly. There may be experienced some deep-seated 
soreness in the lumbar region, then a quick movement as in kicking, 
sneezing, coughing, etc., may give rise to a sudden increase of the sore- 
ness, soon developing into acute pain. Whether the onset be sudden 



550 



DISEASES OF THE KIDNEY. 



or gradual, the attacks are not of equal severity. The difference we 
may suppose to be due to the varying sizes of the calculi. If a calculus 
become impacted, it will ulcerate through and give rise to fatal perito- 
nitis. In a few cases the calculus has occupied a number of days in 
making the journey through the ureter, the most severe suffering, as is 
usual, occurring at last, owing to the increasing narrowness of the lower 
ureter. If repeated attacks occur, the rule is that the succeeding ones 
are milder, but this depends upon the size of the calculi. Gravel and 
sand may occasion no distress at all, or, at most, some little burning at 
micturition. A calculus too large to escape through the meatus uri- 
narius may pass through the ureter without causing recognizable dis- 
turbances. 

If the calculi are retained in the pelvis of the kidney, pyelitis is, as 
a rule, gradually developed. The urine ultimately becomes milky from 
the presence of muco-pus, but there is a long period from the first 
appearance of a slight sediment to the milky-white appearance on emis- 
sion. During this intervening time there is a favorable opportunity 
for diagnosticating the composition of the calculus, following the 
method of Beale, who has shown that, if calculi are contained in the 
pelvis of the kidney, identical microscopical forms may be recognized in 
the sediment. The author has confirmed this observation of Beale, and 
has had in his own cases some remarkable examples of the utility of 
the method. Of course, when calculi of a size to be recognized by the 
naked eye pass, there can be no difficulty in accounting for the occur- 
rence of symptoms indicating the presence of a renal calculus. Besides 
the knowledge gained by a study of the urine, there are other sources 
of information. Patients affected with a calculus suffer with pain ex- 
tending along the ureter upward into the lumbar region and to the 
spine. This pain is also a feeling of soreness and heaviness, which is not 
removed by change of position, and, although alleviated by lying down 
at night, becomes so irksome toward morning as to compel the patient to 
rise, or to make incessant changes of position. More or less frequent at- 
tacks of colic are caused by the passage of plugs of mucus or shreds 
of tissue, but they are not accompanied by the intense suffering pro- 
duced by calculi. If the ureter becomes obstructed, as may happen, 
the pus and the urine, so long as the kidney continues to functionate, 
will accumulate, causing the condition of hydro- or pyonephrosis — the 
latter when there exists a pyelitis. The gradual accumulation of pus 
and the disintegration of the kidney substance will result in the forma- 
tion of a sac with thick walls, presenting evidences of renal structure 
only on careful inspection. A tumor will form of considerable volume, 
projecting downward from the hypochondrium. It may be somewhat 
nodular, irregular, but is more frequently smooth and globular — the 
outline and shape being determined by the degree of accumulation ; 
hence the tumor is the more globular and less nodular the more an- 



RENAL CALCULI. 



551 



cient. The tumor may attain to very large size ; in a case in tlie 
author's charge, it was as large as a child's head. The sac may yield 
and the contents escape into the peritoneal cavity, or a communication 
may be established with the colon or stomach, or discharging posteri- 
orly may open a fistulous communication in the lumbar region, or dis- 
secting downward along the course of the psoas muscle may point 
under Poupart's ligament. The calculus maybe discharged by any of 
these channels. When the ureter is closed, the urine, which before was 
full of pus, now appears clear again. An obstruction of the ureter 
may be temporary, and the urine after a short period of freedom from 
pus may become loaded with it again. When the obstruction yields, 
a sudden gush of purulent urine and debris will cause more or less 
pain or colic ; indeed, the attack may have all the characteristics of a 
severe nephritic colic. 

Course, Duration, and Termination. — Nephrolithiasis develops 
slowly, is very chronic in its course, and variable in the results. The 
exceptions to this statement consist of those cases which terminate 
suddenly by rupture of the ureter and peritonitis, and the very rare 
examples of septicaemia or pyaemia occurring with the beginning sup- 
puration, or of uraemia from the simultaneous blocking of both ureters. 
Renal sand and small concretions may, after a variable period of de- 
tention, pass down the ureter and be discharged with the urine. Often 
concretions of considerable size, too large to pass the meatus urinari us, 
are thus discharged, all symptoms ceasing when the source of irritation 
is removed. Recovery has ensued also by the discharge of the con- 
cretion through a fistulous communication externally, the kidney under- 
going atrophy, the sac closing, and the formation of pus ceasing. As 
one kidney may perform the duty of both, a cure effected in this way 
may be genuine. Death may occur from exhaustion, or amyloid de- 
generation may be the result of the protracted suppuration ; pyaemia, 
or some intercurrent malady, may quickly terminate life in a portion 
of the cases. 

Diagnosis. — Renal colic may be confounded with biliary colic. The 
two affections are frequently associated. They are distinguished by 
the situation of the point of maximum pain, and by the sequelae — 
hepatic colic followed by jaundice and pasty stools, renal colic by ex- 
cessively irritable bladder and bloody urine. Is the calculus present 
uric or phosphatic ? The preponderance of numbers is a presumption 
in favor of uric acid. But the determination is made by an examina- 
tion of the sand, gravel, or microscopic calculi. A uric-acid calculus, 
long present in a suppurating pelvis of the kidney, will become more 
or less deeply incrusted with phosphatic material, and the urine will 
contain phosphate crystals. When a tumor exists, the kidney affected 
is revealed. That one and not both kidneys is the seat of disease 
may be determined by the passage of perfectly normal urine when 



552 



DISEASES OF THE KIDNEY. 



an obstruction, either temporary or permanent, prevents the escape 
of pus. 

Treatment. — As the attack of renal colic requires the most power- 
ful anodynes, morphine hypodermatically should be employed at once. 
As the stomach is highly irritable, it is useless to give medicines by 
the mouth for this purpose. Enemata of laudanum act efficiently if 
sufficient time be given them. The inhalation of ether may be prac- 
ticed until more permanent relief can be given. The warm bath is ser- 
viceable by inducing relaxation. If gravel or sand of uric acid is pres- 
ent, its solution and excretion should be effected as speedily as possible. 
The urine should be alkalinized by the free use of the potash and lithia 
salts ; soda must be avoided, as the urate of soda is not readily solu- 
ble. Probably the best preparation is the officinal liquor potassii citra- 
tiSj of which a tablespoonful may be taken every three hours. Recently 
the borocitrate of magnesium and the benzoate of lithium * have been 
used successfully, both of these agents having remarkable solvent ef- 
fects on uric-acid calculus. The experiments of Roberts,! however, 
seem conclusive as to the solvent action of the potash salts ; these fail- 
ing, the borates and benzoates may be tried. Nothing can be accom- 
plished by spasmodic efforts. The solvent action must be maintained 
without intermission for a long period. Should the protracted exist- 
ence of a uric-acid calculus, with pyonephritis and alkaline urine, render 
it probable that an incrustation of phosphates has occurred, the benzo- 
ate of ammonia should be prescribed, as the most certain means of 
bringing about an acid condition of the urine. If the calculus is phos- 
phatic, the same procedure is proper to produce and maintain an acid 
state of the urine until the phosphatic incrustation or the phosphatic 
calculus is dissolved. When this is accomplished, the method above 
mentioned must now be pursued. In the treatment of pyelitis those 
remedies are to be employed which are eliminated by the kidneys and 
exert a local action — copaiba, cubebs, santalum, juniper, erigeron, euca- 
lyptol, turpentine, etc. These must be used with caution, because of 
their irritant effects on the kidneys. Probably the most generally use- 
ful, and at the same time safe, is eucalyptol. This should be admin- 
istered in small doses, relying upon the results of a slight impression 
maintained for a long time. Any of the members of this group may 
be employed instead of eucalyptol, under the same limitations. The 
so-called diuretics — scoparius, squill, buchu, pareira, etc. — have also 
been recommended, but they are less effective than the oils. Canthari- 
des tincture has been prescribed in small doses with advantage in pye- 
litis. The free use of skimmed milk, and buttermilk when it is grate- 
ful or preferred, is decidedly beneficial. When the existence of the 
tumor can be made out clearly, it should be evacuated posteriorly by 

* "Bulletin General de Therapcutique," January SO, 1880. 
•jr "Urinary and Benal Diseases," op. cit. 



HYDRONEPHROSIS. 



553 



the aspirator. If the calculus can be reached, a free opening should 
be made and a drainage-tube inserted. The sac can then be kept 
thoroughly empty, clean, and in the most favorable condition for 
shrinking and ultimate closure. Recovery has ensued. In a case of 
the author's in which the sac was opened from behind, the calculus was 
removed and free drainage secured, but the patient was exhausted by 
protracted suppuration. 



HYDRONEPHROSIS— DROPSY OF THE KIDNEY. 

Definition. — Hydronephrosis consists in an accumulation of the 
urine and dilatation of the pelvis and calyces, with progressive atrophy 
of the renal structure. 

Causes. — Hydronephrosis may be congenital or acquired. When 
congenital it is due to some anatomical anomaly. It is more common 
in women than in men, because of the functions peculiar to the 
former. Obstruction of the ureter is the usual cause ; the nature of 
the obstruction may differ greatly. The ureter may be blocked by a 
calculus, by inflammation and adhesion of the mucous surfaces, by 
constriction of a band of lymph, by pressure of a tumor, by the dis- 
placed uterus, etc. When an obstruction is caused by the impaction 
of a calculus, it is usually found in situ ; but not invariably so, for 
sometimes the calculus crumbles and disappears. 

Patliolog^i'^al Anatomy. — The dilatation will involve the more of 
the ureter, the lower down the obstruction is placed. The degree of 
damage done to the kidney will, of course, be determined by the 
amount of fluid. In an extreme case the kidney-structure will have 
disappeared, nothing remaining but a huge membranous bag, the 
ureters distended into somewhat tortuous cylinders the size of a small 
intestine, and with more or less thickened walls. When the accu- 
Ko. 2. mulation is small in amount, the pelvis 

'<sh ^ ^ somewhat dilated, the calyces also, and 

!^^^^ papillae are flattened. As the fluid in- 

^^^^] ^^^^^A^[\^ creases, there will be increasing atrophy of 



2^ fi/f "^^^^^fe^ /) j ^^^^ kidney, the medullary portion first dis- 
appearing, and ultimately the cortical part. 
No.rurtte7^No!'2!uTethra. The sac may be of enormous dimensions, 
filling half the abdominal cavity, displacing 
organs and contracting adhesions to neighboring parts. The colon 
may be compressed and adherent very closely to the walls of the sac. 
The original capsule of the kidney, thickened by new connective tis- 
sue, forms the walls of the sac, the lobulated appearance being due to 
the internal septa. The fluid in the sac is modified urine — it is pale, 
of low specific gravity, alkaline in reaction, and contains urea, uric 
acid, urates, etc., or it may be brownish in color from the presence of 



554 



DISEASES OF THE KIDNEY. 



blood, or yellowish and turbid from the presence of pus (pyonephritis). 
The fluid usually contains traces of albumin, which may be consid- 
erable if blood is present, and more or less epithelium may also be 
occasionally found. The accumulation is usually limited to one kid- 
ney, the other being enlarged to compensate for the absence of its 
fellow. 

Symptoms. — It is an extremely rare event for both kidneys to be 
affected, and hence uraemia is not a common, is indeed a rare symp- 
tom. The accumulation occurs silently, and hence it is the formation 
of a fluctuating tumor that first attracts attention. The size depends 
somewhat on the age of the growth ; it may have the dimensions of a 
child's head. In growing, adhesions form, which give rise to acute, 
stabbing pains at the time of their formation. When the tumor at- 
tains sutiicient volume to displace or compress the neighboring organs, 
corresponding disturbances are occasioned. If the colon is compressed, 
great accumulation of faeces will take place above that point ; if the 
diaphragm is pushed up, dyspnoea will result ; if the stomach is pressed 
on, there will be nausea and vomiting ; if the tumor rests on the ab- 
dominal aorta, a pulsation will be communicated to it. It is important 
to note that the colon in hydronephrosis of the left side may lie in 
front of the tumor. The author saw a surgeon pass a trocar through 
the large intestine to reach the sac ! The tumor has usually some 
firmness, does not fluctuate very easily, although distinctly, and is not 
movable. It may be handled freely without pain, as a rule, unless 
adhesions have recently formed, when it will be tender. 

Course, Duration, and Termination.— The course of hydronephrosis 
is chronic, the onset obscure, the formation of a tumor slow, and the 
final disposition of the sac a tedious process. Years will be occupied 
in the development of these several stages. A genuine cure is rarely 
effected. It may happen that an obstruction within the ureter yields 
and the water flows away, but this is very uncommon. If the accumu- 
lation be due to pressure of a displaced uterus, a cure is readily effect- 
ed by correcting the displacement. When not remediable, the ter- 
mination is ultimately fatal, death being due to the complications 
arising from the pressure on organs, or, the sac giving way, general 
peritonitis is the result. 

Diagnosis. — Hydronephrosis is most frequently confounded with 
ovarian tumor. The former develops from above, the latter from 
below. The withdrawal and examination of the fluid are usually ne- 
cessary to come to right conclusions. The fluid of hydronephrosis is 
usually watery and contains urea, uric acid, and epithelium ; the fluid 
of ovarian disease contains the compound, granular, many-nucleated 
corpuscles, is dark in color, and somewhat gelatinous in consistence. 
Hydronephrosis may be confounded with ascites when both kidneys 
are affected. They are to be distinguished by the changes in the posi- 



CANCER OF THE KIDNEY. 



555 



tion of tlie dullness, on changes of posture in cases of ascites, which 
do not occur in hydronephrosis. In the beginning of ascites, if the 
patient lies recumbent, the dullness is in the flank ; in hydronephrosis 
the dullness is at the site of the tumor, and does not change its 
position. 

Treatment. — The sac has been emptied by careful manipulation, 
the obstruction yielding to pressure. This treatment is applicable but 
rarely. If the accumulation is sufficient to endanger life, the aspirator 
may be used, but otherwise interference is to be deprecated. 

CARCINOMA OP THE KIDNEY. 

Causes, — Nothing is definitely known of the causes of cancer of the 
kidney. It may be primary or secondary. It occurs in early life 
— before five — and in old age, youth and manhood to middle age being 
comparatively exempt. As regards sex, cancer of the kidneys is more 
common in men. 

Pathological Anatomy. — Primary cancer rarely involves both kid- 
neys, and of the two the right is the more frequently attacked. When 
cancer of the kidney is secondary, the organ attacked by contiguity, one 
only is affected, but, if there exists a general carcinoma, both will be the 
seat of deposits. The cancerous kidney attains to great size — accord- 
ing to Rindfleisch to twelve inches in length and six inches in width, 
and to a weight of sixteen pounds (Spencer Wells). This enormous 
size is attained in a very short time. Again, although very rarely, the 
kidney may not be enlarged by cancer deposits. The shape of the 
organ may be exactly preserved, or there may be irregularities and 
nodosities ; in the former the organ on section presents a uniform 
whitish or yellowish surface ; in the latter the cancer-masses occur in 
distinct nodules, separated by a defined line from the normal tissues, or 
become encapsulated. The vessels of renal cancer are abundant, large, 
and have thin walls, are consequently easily ruptured, the blood collect- 
ing in large excavations. Usually there is very considerable hyperasmia 
of the interstitial connective tissue, which assumes an active hyper- 
plasia. Sometimes there is found in the midst of a mass an isolated 
soft detritus, made up of cells which have undergone fatty degenera- 
tion and may have a foul odor. The cancer elements, according to 
Waldeyer,* whose views are accepted by Rindfleisch, f develop from 
the epithelium of the tubules. The form taken by the cancer is deter- 
mined by the relative proportion of fibrous stroma and cells and blood- 
vessels. The more abundant the vessels and cells, the softer and more 
rapidly growing the cancer, which is then called the medullary carci- 
noma. If the fibrous framework or stroma is in excess, then the can- 



* Yirchow's " Archiv," op. cit. 



f " Pathological Anatomy," p. 512. 



556 



DISEASES OF THE KIDNEY. 



cer becomes scirrhous. The cancer may spread to and involve the 
pelvis and ureter, and the latter may be filled up with cancer-masses. 
The pelvis may be filled with blood-clots, stratified as in aneurism. 
The cancer elements may invade the renal vein, reach into the vena 
cava by coagula, whence emboli are detached, and lodge in the lungs. 
The cancerous kidney may contract adhesions to adjacent parts, and 
is apt to do so, or, detached by its increased weight, may become mi- 
gratory or floating. If it remains in its own position and enlarges to 
the enormous extent that sometimes occurs, neighboring organs may 
be much displaced and compressed, those of the thorax as well as those 
of the abdomen. 

Symptoms. — Cancer of the kidney may develop to a considerable 
extent without producing any characteristic symptoms. Pain may be 
experienced to a greater or less degree in the beginning, but it does 
not differ from pain due to other causes. It is felt in the lumbar 
region, under the false ribs, external to the spine, and is a sensation of 
soreness merely, rather than the acute, lancinating pain traditional of 
cancer. With or without pain, ha&maturia occurs, and is the first 
symptom to awaken a suspicion of the nature of the malady, but this 
symptom is present in one half of the cases only. It is not constant, 
and there may be considerable intervals of a few days, weeks, or 
months between the haemorrhages. Its appearance may be postponed 
until near the end. It not unfrequently happens that some external 
injury, a blow, a fall, determines the haemorrhage or increases its vio- 
lence. Rarely is the quantity of blood sufficient to cause dangerous 
exhaustion. The urine may present a faint, smoky hue ; it may be 
reddish or reddish-brown ; it may contain clots of various sizes. The 
corpuscles are more or less crenated and otherwise altered when the 
urine is merely smoky, but when the quantity of blood is considerable 
the corpuscular elements are normal. So long as the blood is inti- 
mately mixed with the urine, there is no pain connected with it ; but, 
when clots of considerable size are forced through the ureter, the pain 
will be agonizing — only less severe than that due to the passage of a 
calculus. Although in the beginning there may be only some deep- 
seated soreness, or no pain of any kind, in the further progress of the 
case pains will come on. The pain may be deep and rather dull in 
the neighborhood of the kidney or in the lumbar region, or it may be 
sharp, lancinating, and radiate along the intercostal nerves, or down- 
ward into the hip, the whole of the corresponding lower limb feeling 
benumbed and heavy. Sometimes excruciating sufferings are expe- 
rienced in the sciatic nerve by pressure of cancerous lymphatics, and 
the limb rapidly wastes. Sufficient enlargement of the kidney to con^- 
stitute a tumor is the most constant symptom. In sixty-four cases a 
tumor of the abdomen was recognized in all but three, and in nearly 
all of these was of a size to be recognized on a cursory examination 



CAJfCEE OF THE KIDNEY. 



557 



(Roberts). The tumor pushes forward into the anterior part of the 
lumbar region and grows upward into the hypochondrium and down- 
ward toward the iliac regions. In children the tumor attains the largest 
growth, filling the entire abdomen. As the colon lies in front usually, 
and as the material of the cancerous kidney is soft, the tumor does 
not furnish a dull or flat note on percussion, but a distinctly tym- 
panitic note. Full inspiration or expiration does not affect the posi- 
tion of the tumor, which is usually, but not invariably, immovable ; 
the cancerous kidney may also be a movable or a floating kidney. 
By carefully relaxing the abdominal muscles the form and density of 
the tumor may be ascertained. It will be found somewhat elastic, 
round, and smooth, or hard, firm, and nodular. There may be a 
ramification of enlarged veins on the abdominal surface of the tumor, 
and it may have a pulsation in it, communicated from the abdomi- 
nal aorta. If hsematuria is absent, the urine may be normal in amount 
and quality. It occasionally happens that albumin is present when 
there is no blood, because of a coincident Bright's disease. Uraemia 
does not occur because the disease is unilateral, but both organs may 
be involved. When a calculus is present, as is not unusual, pyelitis will 
complicate the renal symptoms. Particles of broken-down tissue and 
the so-called cancer-cells are sometimes to be found in the urine, but 
unfortunately there is no distinctive cancer-cell. The digestion may 
be unimpaired, the appetite keen, even voracious, but the rule is that 
the appetite is poor, there is nausea, and the body wastes. With the 
first symptoms there is emaciation, which ultimately becomes extreme. 

Course, Duration, and Termination. — This disease does not pursue 
the same course in all cases. In children the progress is more rapid, 
the mean duration being seven months (Roberts), whereas in adults 
the average duration was two and a half years. In some cases in chil- 
dren the duration is counted by weeks, and one case is noted as occur- 
ring in an adult which lasted eighteen years. The termination is inva- 
riably in death. Sometimes unexpected improvement takes place, but 
evil symptoms come on again presently. 

Diagnosis. — Cancer of the right kidney may be mistaken for a tu- 
mor of the liver. It is usually possible to demonstrate a sulcus be- 
tween the liver and the enlarged kidney, or to insinuate the fingers 
between the two. The position of the colon is an important element, 
for lying in front of the kidney modifies the percussion-note, which is 
dull-tymjmnitic over the kidney and flat over the liver. From an en- 
larged spleen it is to be distinguished by the evolution and position 
of the tumor ; by the situation of the colon — in front of the renal and 
behind the splenic tumor ; by the shape and thickness of the tumor— 
the spleen having a rounded margin and comparatively thin edge 
which may be grasped ; by the history of the case — malaria or leu- 
cocythemia of a splenic tumor ; by the urine, containing blood and 



558 



DISEASES OF THE KIDNEY. 



cancer elements, etc. From ovarian tumor the differentiation is made 
by the position of the growth, the mode of its development, by its 
form ; by the position of the colon, again ; by the occurrence of hsema- 
turia, etc. From accumulations in the large intestine, in the caecum 
— the descending colon — the kidney-tumor is recognized by its size, 
outline, position, and percussion, by haBmaturia, by the action of a 
cathartic, or irrigation of the bowel. As cancerous tumors of the kid- 
ney sometimes pulsate, they may be mistaken for aneurism. If the 
patient be placed on the elbows and knees, so that the tumor may 
glide away from the aorta on which it lies, the pulsation will cease. 
If a fixed tumor, this expedient can not be practiced. A fixed tumor 
of that kind pulsating, will produce no expansile movement. It will be 
very confusing if a minute communication exist between the aneurism 
and pelvis of the kidney, for then haematuria will coexist with a tumor. 

Treatment. — The remedial management is merely symptomatic, and 
is chiefly confined to measures for the relief of pain. 

TUBERCULOSIS OF THE KIDNEY. 

Pathogeny. — The deposit of tubercle occurs in the two forms — 
disseminated, localized. In the disseminated form, gray granulations 
are scattered through the renal parenchyma, and are developed from 
the sheaths of the vessels, and this form is a part of a general morbid 
change. It is the localized form with which we are chiefly concerned 
here. The deposit of tubercle-masses begins at the renal papilla by 
an extension of the morbid process taking place in the calyces and 
pelvis. The miliary nodules aggregating, assume the cheesy aspect, 
soften in the center, are extruded, carrying with them the portion of 
tissue embraced in the deposit. Thus an excavation is established. 
The kidney usually increases somewhat in size ; it becomes nodular, 
and the capsule, thickened and indurated, contains various foci of 
cheesy deposit. The whole organ is ultimately converted into a mere 
bag with thick walls and projections inwardly of connective-tissue 
septa, the remains of the original calyces. The testes and epididymis 
are, in the majority of instances, the seat of the initial changes, and 
spread thence to the kidneys, or they may begin in the bladder and 
extend thence into the kidneys. The same cheesy infiltration takes 
place in the pelvis, ureters, and bladder. 

Symptoms. — The urine is increased in amount, and contains, when 
the disease is developed fully, blood and pus, the reaction is acid, and 
albumin is present. In the further progress of the case, the urine be- 
comes ammoniacal, alkaline, and thick with pus and detritus. When 
the disease has reached the sub-mucous tissue, shreds of elastic tissue 
and fragments of cheesy matter, with the bacillus tuberculosis, which 
indicate clearly the nature of the destructive changes, appear in the 
urine. Micturition is frequent and more or less painful. This is due 



HYDATIDS OF THE KIDNEY 



559 



to the tubercular ulceration of the mucous membrane of the bladder, 
and the catarrh which accompanies it. More or less pain is expe- 
rienced in the lumbar region, which may be a feeling of soreness and 
fatigue combined, or of acute pain, paroxysmal in character. Besides 
the lumbar pain, there are paroxysmal attacks of pain in the back, ex- 
tending along the ureter, attended with frequent and painful mictu- 
rition, produced by the passage of shreds of tissue or cheesy masses. 
There may be no pain. Obstruction to the ureter taking place, there 
may ensue an enlargement of the kidney of sufficient size to constitute 
a tumor. The obstruction yielding, the accumulated pus and urine 
will flow away, and the tumor will collapse ; but when the tumor once 
forms, although it may vary in size, it does not entirely disappear. 
With the progress of the tubercular ulceration, there is increasing de- 
struction of the renal substance, and hence the quantity of urine is con- 
stantly declining. As both kidneys are usually affected, ursemic symp- 
toms come on, when the excretion of urea and other effete materials is 
prevented. Usually, however, the patient is carried off by the prog- 
ress of the tubercular ulceration in the intestinal canal and lungs. In 
the author's cases, there were simultaneous pulmonary lesions, which, 
however, seemed to make but little progress. Death occurs by exhaus- 
tion, or with some head troubles. 

Course, Duration, and Termination. — The course and duration are 
much affected by the existence of general tuberculosis, b}^ the extent 
of mischief in both kidneys, and by the degree in which the bladder 
is implicated. The duration rarely exceeds one year, though there are 
occasional examples lasting two, even three years. If the bladder is 
much affected, the pain and irritation and the loss of sleep from fre- 
quent micturition rapidly exhaust the vital powers. If both kidneys 
are largely damaged, the case will be terminated by cerebral hsomor- 
rhage, or by coma and convulsions. 

Treatment. — The best results as regards prolongation of life are 
obtained by the use of quinine in considerable doses (five grains ter 
in die), the benzoates, salicylates, and eucalyptol. To relieve the 
irritable bladder and permit sleep, the most suitable remedies are 
chloral and morphine by suppository or enema. If the cystitis is 
very severe, and the urine ammoniacal, good results are obtained 
by the author by irrigation of the bladder with a weak solution of 
salicylic acid and borax. 



ECHINOOOCCUS OF THE KIDNEY— HYDATID CYST OF THE 

KIDNEY. 

Definition. — Ediinococcm of the kidney , like echinococcus of the 
liver, is the immature or larval condition of the taenia echinococcus^ the 
tape-worm of the dog. 



560 



DISEASES OF THE KIDNEY. 



Pathogeny. — According to Davaine, this parasite is rarely found in 
the kidney. It is a sac composed of several layers, transparent and 
hyaline, the mother-sac, and within it are contained a watery fluid and 
a number of small vesicles (daughter-vesicles), attached to the brood- 
capsule (mother-sac) or floating freely. These daughter-vesicles vary 
in size from a grape-seed to an orange — the largest containing their 
own progeny, or granddaughter - vesicles. As the daughter-vesicles 
enlarge, the brood-capsule with its germinating layer also enlarges. 
Within each capsule or vesicle is seen the scolex, or so-called head with 
its suckers and row of booklets. The fluid of the vesicles is watery, 
albuminous, and saline, and contains, besides chloride of sodium, crys- 
tals of uric acid, oxalate of lime, triple phosphates, and plates of cho- 
lesterine. The parent-vesicle is inclosed in a vascular, white, dense 
connective-tissue tunic or envelope, one half to two or three lines in 
thickness, and firmly adherent to the surrounding gland-substance. 
The size of the cysts varies from a small marble to a child's head, and 
it is situated in the substance of the kidney, and occasionally between 
the capsule and the gland-structure. The pressure of the enlarging 
cyst induces atrophy of the adjacent renal substance, until ultimately 
the whole organ may be destroyed. Rupture may take place into the 
pelvis of the kidney, but not into the peritoneum, this untoward result 
being prevented by a limiting adhesive peritonitis. Adhesions are also 
formed with neighboring organs. Sometimes the cysts are sterile, and 
consist of a single cavity. The growth may be arrested and the cyst 
undergo calcareous degeneration mixed with a fatty change. In two 
thirds of the cases a rupture of the cyst takes place into the pelvis, and 
pyelitis is produced thereby. 

Symptoms. — As the parasite is deposited in one kidney — a rule to 
which there are but few exceptions — and as no disturbance is caused 
in the functions of the affected organ until the parasite has attained a 
certain development, it is obvious that the first period of growth will 
escape recognition. As the tumor enlarges, neighboring organs are 
displaced, and as inflammatory attacks are excited and adhesions 
formed, these will be accompanied by attacks of pain and f everishness. 
Usually only the symptom of a tumor, smooth and elastic, in the flank, 
is experienced, and for which advice is sought. According to Roberts's 
statistics, of sixty-three cases of hydatids of the kidney, only eighteen 
presented the symptom of a tumor, varying in size from an orange to 
an adult's head.* Fluctuation was distinct in part, feeble in others, 
and not perceived in the rest. The most characteristic symptom is 
the " purring tremor," " the hydatid thrill," unfortunately a symptom 
which is not often encountered. It can be produced only when there 
are numerous daughter-vesicles inclosed in the mother-sac, the thrill 



* " Urinary and Kcnal Diseases," p. 572. 



HYDATIDS OF THE KIDNEY. 



561 



being caused by the collision of these elastic bodies. The tumor will 
usually have the colon in front, but it may be at one side. The dull- 
ness on percussion will be much influenced by the position of the bowel, 
which must always be taken into consideration. As the cyst in a ma- 
jority of cases tends to rupture into the pelvis of the kidney, the symp- 
toms connected with this are of great importance. Vesicles, shreds of 
the germinating layer, and an emulsion of milky appearance contain- 
ing fragments, booklets, and oil-drops, are discharged with the urine, 
and at once indicate the character of the case, the microscope being 
used to find the booklets. The rupture of a sac into the pelvis of the 
kidney is usually announced by the occurrence of sharp pains in the 
region of the kidney, with a sensation of something giving way. This 
geems all the more probable if, as has been the case, the patient has re- 
ceived a blow in the side, followed by the sensation of something giving 
way. The pain descends by the ureter, the testicle is retracted, the sur- 
face cold, and the pulse feeble. The severe attacks of renal colic are 
comparatively rare, but some pain in the loin and down the ureter is 
usual. The paroxysms do not continue longer than a few hours, or a 
day or two, to be resumed again at variable intervals of a few weeks, sev- 
eral months, or even three years. When the vesicles reach the bladder, 
the pain of renal colic ceases ; but new troubles arise in the attempt to 
pass these bodies by the urethra. Violent vesical tenesmus comes on, 
pain is felt at the glans penis, and with severe straining the vesicles 
are passed, but not unfrequently the aid of the catheter is necessary 
to empty the bladder. If there be a single mother-vesicle, the dis- 
charge of the daughter-progeny may end the symptoms by the shrink- 
ing and closure of the sac. The sac may be much reduced in size by 
the discharge, but fills up again, the same phenomena being repeated 
from time to time. 

Course, Duration, and Termination. — The course of hydatids of the 
kidney is chronic, and the duration uncertain. If a single cyst is pres- 
ent, the discharge of its contents may terminate the case, but usually 
there are several discharges. The cases may terminate by rupture into 
the peritoneum, which is unusual, by bursting into a bronchus, by ex- 
citing pleuritis, by suppuration in the sac, by some intercurrent malady, 
and by recovery, which occurs in about two thirds. 

Diagnosis. — If there be present a tumor, and parasites are discharged 
with the urine, the size of the tumor diminishing, there can be no 
doubt. Microscopic examination will determine the character of the 
milky fluid, or shreds passed. If no tumor can be detected, the dis- 
charge of vesicles with the symptoms of nephritic colic will indicate 
the probable seat of the mother-sac. If a tumor exist without the dis- 
charge, it can not be distinguished from hydronephrosis. 

Treatment. — The pain and disturbance caused by the passage of 
the cysts must be treated as renal colic. If the cysts are enlarging, 
38 



562 



DISEASES OF THE KIDNEY. 



an attempt should be made to destroy them. Electrolysis has been 
proposed for this purpose, but it appears the attempts which have been 
made have not succeeded. Injection with tincture of iodine, or with 
bile, which seems very poisonous to these parasites, should be prac- 
ticed. 

MOVABLE KIDNEY. 

Definition.— By this term is meant a kidney become abnormally 
movable. It is sometimes called Jloati?ig hidney. 

Causes. — -The kidney may have an unusual mobility, by reason of 
anatomical peculiarities. The peritoneum may be reflected in front 
and behind, constituting a mesos permitting free motion to the organ. 
In its natural position imbedded in fat, having the peritoneum in 
front, and unsupported by ligaments, it is so placed as to be readily 
dislocated. Should the fat be absorbed, or the peritoneum relaxed, the 
kidney becomes abnormally movable. This disability is more common 
i»n women than in men (ten to two, about), a difference due to two 
factors — to tight lacing, and to pregnancy. Pregnancy by the great 
distention of the abdomen, relaxes the peritoneum, and thus removes 
the principal support. Tight lacing forces the liver down, which 
pushes the kidney before it, but on the left side the organs have more 
room. The right kidney is affected in the majority — in Roberts's col- 
lection of sixty-five cases, the right kidney was movable in forty-two, 
the left in nine, and both in fourteen. If the weight of the organ is 
increased by any cause, the tendency to displacement is proportionately 
increased. Usually, however, an enlarging kidney contracts inflam- 
matory adhesions to neighboring parts, and thus dislocation is pre- 
vented. 

Pathological Anatomy. — The congenital movable kidney is distin- 
guished from the acquired by abnormal arrangement of the vessels or 
peritoneum, or of both. In the acquired mobility the organ is rather 
elongated, without fat, and detached from the peritoneum. The degree 
of mobility varies, but the extreme length is not greater than the 
length of the vessels which form the pedicle. Attacks of perinephritis 
are common, and hence the kidney may be surrounded by old exuda- 
tions and bands of adhesion. The dislocated kidney may become at- 
tached again and cease to give any more trouble. 

Symptoms. — When displaced, the kidney may descend to the mar- 
gin of the iliac region, but it is usually felt about midway between the 
inferior border of the ribs and the umbilicus. If the patient is thin, 
the outline of the organ can be distinctly made out, and it may even 
be grasped by the thumb and fingers, the pressure producing a sicken- 
ing pain and faintness. The kidney may also be pushed about, and 
upward and backward into its proper position, but it will not remain, 
descending as soon as the support is withdrawn. Respiration changes 



MOVABLE KIDNEY. 



563 



its position also : it descends on full inspiration ; ascends on full ex- 
piration. Percussion does not afford a flat note, but a dull tympanitic 
note. Over the normal site occupied by the kidney, there will be, 
instead of a flat note on percussion, a hollow tympanitic sound. 

Besides the presence of a movable body in the abdomen, which 
always excites apprehension, there may be no other symptom. In other 
cases there may be only soreness in the kidney, and a deep-seated sense 
of aching and pain, with a dragging feeling in the back and loins. 
Usually, the most pronounced symptoms are those connected with the 
digestive organs : the appetite is poor, the bowels are constipated, 
there is much flatulence, and at the same time they suffer from pain in 
the rambling kidney, and aching and dragging in the loins. This 
group of symptoms has a paroxysmal character — there are intervals 
not of entire exemption, but of relief. The intestinal disorders some- 
times take the character of cholera morbus, the attacks occurring every 
few days or weeks, and between them the digestion is troubled, and 
there is much flatulent distention. 'Now and then there are cerebral 
attacks — extreme vertigo, headache, nausea, and vomiting, due prob- 
ably to twisting of the ureter and retention of urine, congestion of the 
kidney, etc., and followed by bloody urine, purulent sediment, and 
finally a copious urinary discharge, the symptoms subsiding. Again, 
in other cases, there will be much pain and tenderness experienced 
about the kidney, and requiring confinement to bed, feverishness, a 
coated tongue, headache, scanty, acid urine, etc. — symptoms probably 
due to attacks of local peritonitis or adhesive inflammation. In a case 
of displaced right kidney in a male, there were obstinate constipation, 
small, flattened faeces, persistent flatus with the sensation of passing an 
obstacle, due to the position of the kidney against the ascending colon. 
In ail cases, causing symptoms, there is much hypochondriasis, or de- 
pression of spirits, even suicidal feelings. 

Course, Duration, and Termination.— The cases continue indefinitely. 
It sometimes happens that the kidney secures firm attachments again, 
but the author has seen but a single example of such termination. A 
dislocated kidney is more liable to degenerative changes than a fixed 
one. 

Diagnosis. — As no other tupior behaves as the movable kidney, the 
diagnosis ought to be easy. The diagnosis rests on these data : the 
tumor has the shape and size of the kidney ; it descends from the posi- 
tion occupied by the kidney, and can be pushed back into the same ; 
it has a special sensibility ; the position which the kidney normally 
occupies is found to be vacant. 

Treatment. — As the chief distress arises from the movable condition 
of the kidney, an attempt should be made to confine it to its proper 
place by a suitable bandage. The patient must be recumbent, the 
muscles of the abdomen relaxed ; then the kidney is pushed back, a 



564 



DISEASES OP THE KIDNEY. 



compress is so placed as to prevent its descending, and a closely fitting 
bandage must then be fastened around the abdomen, so arranged that 
the support is from below upward. Attention must be paid to the 
diet, and flatulent-forming food given up entirely. Constipation must 
be avoided, and the bowels kept in a soluble state. If anaemia exist, a 
course of chalybeate tonics will be necessary. The secretion of urine 
should be closely observed, to discover changes in time. 

PERINEPHRITIS. 

Definition. — perinephritis is meant an inflammation of the loose 
connective tissue about the kidney. This term is comparable to perity- 
phlitis. As the ordinary result is suppuration, it may be comprehended 
in the term perinephric abscess, as employed by Trousseau. 

Causes. — Penetrating wounds, contusions, and even strain (Trous- 
seau) will excite inflammation of the perinephritic connective tissue. 
Pelvic cellulitis may extend upward by the subperitoneal connective 
tissue, and ultimately involve the renal. This, although often a puer- 
peral process, may arise from operations on the pelvic organs, etc. 
Operations on the rectum and inflammatory affections about the blad- 
der may also produce the same result. Chronic pyelitis may extend 
to and involve the perinephric connective tissue. This disease occurs 
at adult life till old age, and is more common in men than in women. 

Pathological Anatomy. — The connective tissue is at first the seat of 
an intense hypersemia ; suppuration soon follows, the purulent elements 
being mixed with blood, and presenting therefore a grumous aspect ; 
the area of suppuration is not limited, the boundaries of the pus being 
shreds of breaking-down tissue, the abscess enlarging irregularly. The 
pus presently becomes yellowish and homogeneous, and something like 
well-defined limits surround it, but the tendency is to spread along the 
retroperitoneal connective tissue. An enormous accumulation may 
take place. The disposition of the abscess occurs in various ways : it 
may rupture into the peritoneum, exciting general peritonitis ; it may 
dissect through and discharge externally in the lumbar region ; it may 
open the colon and discharge by the bowel ; it may burrow along the 
psoas muscle and open underneath Poupart's ligament, or at the lesser 
trochanter, etc. 

Symptoms.— Pain is a very usual and persistent symptom. Often 
it begins with the blow or strain, and is a deep-seated aching in the 
lumbar region, increased by firm pressure, by bending the body, and 
is not relieved by changes of position, but it sometimes ceases for 
days, even weeks, but when it returns is more severe than before. 
With the first pain there is more or less chilliness, followed by fever, 
general malaise^ nausea, anorexia, a coated tongue, etc., the fever 
rising to 103°, 104°, or even higher. The fever has the remittent 



PERINEPHEITIS. 



565 



type, with a morning remission, and there is considerable sweating, 
especially toward morning. A severe rigor announces suppuration, and 
chills occur subsequently irregularly, and are followed by high fever 
and profuse sweats. The body emaciates ; the appetite is gone ; there 
is vomiting ; an obstinate constipation, requiring active purgatives to 
relieve it, comes on ; the skin acquires the yellowish, earthy hue or 
fawn-color of suppuration. After a time, a swelling is discovered in 
the flank, and the depression, which normally exists in the lumbar 
region, assumes a convex shape. On careful manipulation, deep- 
seated fluctuation may be detected. If left to pursue its course un- 
disturbed, the pus finally points in the lumbar region. The pus may 
be odorless, or it may have a fecal odor without any communication 
with the bowel. If the abscess discharges, and there is no complica- 
tion, the condition of the patient at once improves, the fever ceases^ 
the appetite returns. If the pus burrows downward, the duration is 
more protracted, and there is much pain, the abscesses opening in the 
groin. Discharge taking place by the lumbar region, extensive em- 
physema, occupying the whole extent of the back, may occur (Trous- 
seau). In such cases communication is established with the bowel, 
and hence the emphysema is due to the intestinal gases. Faeces may 
be discharged by the lumbar opening, and recovery ensue. If rupture 
into the peritoneal cavity occurs, intense peritonitis, with the usual 
symptoms, will be excited. Rupture into the pelvis of the kidney 
will be announced by the sudden discharge of pus in the urine. 

Course, Duration, and Termination. — The symptoms are very 
obscure until the fluctuating tumor appears ; the cases then pursue 
a very uniform course, and the primary form, rapid course. Discharge 
of pus may terminate an uncomplicated case in three or four weeks. 
Recovery is the usual termination in such cases. Extensive and pro- 
tracted suppuration will induce a typhoid state and death by exhaus- 
tion. Rupture into the intestinal canal is rapidly fatal. When com- 
munication is established with the colon, recovery may ensue, but the 
result is doubtful. When the abscess is secondary to puerperal pro- 
cesses, the termination is usually in death. In a few cases, the in- 
flammation of the perinephric tissue undergoes resolution without 
suppuration. The morbid process may produce or succeed to pyelitis, 
or the kidney itself may become diseased — results which aggravate 
the existing disease. 

Diagnosis. — Perinephritis may be confounded with hydronephrosis^ 
echinococcus, and cancer. In all of these diseases a tumor exists : in 
perinephritis, accompanied by fever and sweats and the other evi- 
dences of suppuration ; in hydronephrosis and echinococcus, an en- 
larging tumor without pain ; in cancer, a painful tumor and hjsma- 
turia. Perinephritic abscess tends outwardly to point in the lumbar 
region, or downward, in the groin, while the other tumors grow for- 



566 



DISEASES OF THE NERYOUS SYSTEM. 



ward and downward into the peritoneal cavity. Pyelitis with tumor 
is distinguished from perinephritis by the condition of the urine. 

Treatment. — With the first symptoms, leeches may be applied to 
the lumbar region, followed by ice. Purgatives should be adminis- 
tered. If there is much pain, morphine is necessary. Large doses of 
quinine (ten grains every four hours) should be given with the view 
to check the migration of the white corpuscles, and preferably with 
morphine, although the pain may not be great. As soon as suppura- 
tion occurs, supporting measures are required. Malt liquors, a gener- 
ous diet, alcoholic liquors, and quinine are the most appropriate means. 
A free incision should be practiced as early as possible, and drainage 
established. 



DISEASES OF THE NERYOUS SYSTEM. 



CLINICAL EXAMINATION — MODES OP ASCERTAINING THE 
STATE OF THE NERVOUS APPARATUS. 

Cerehmm. — The examination into the functions of the cerebrum 
includes the study of the mental condition, of the organs of special 
sense, and of the state of common sensibility in the area of distribu- 
tion of the sensory nerves supplying the head and face. 

The intra-cranial circulation is investigated through the facial 
vein, and the appearance of the membranum tympani and the retina. 
When an obstacle to the intra-cranial circulation exists sufficient to 
compress the cavernous sinus, the conjunctiva is injected, the eyelids 
swollen, and the nasal mucous membrane is congested and bleeds 
readily. These results come from the anatomical connection between 
the facial vein and the pterygoid plexus of veins. When there is 
cerebral congestion, or anaemia, the membranum tympani exhibits a 
more or less vivid redness, or an appearance of pallor. 

Ophthalmoscopy. — The retinal circulation being a diverticulum of 
the cerebral, valuable information is gained by ophthalmoscopic ex- 
amination. The ophthalmoscope used for this purpose should be a 
metal concave mirror, of ten or twelve inches focus, with a revolving 
disk behind it provided with ocular glasses. Loring's or Knapp's are 
well suited to this purpose. The observer should be provided also 
with two convex object glasses, having two to four inches focus, and 
a concave lens — the latter for the direct method of examination. 

Both the direct and indirect methods of examination are to be 
employed, as a rule. In the former the eye-ground is illuminated by 



CLINICAL EXAMINATION. 



567 



the mirror, and the observer, seated close to the patient, looks through 
the pupil down on the retina, as one would look into a closed room 
through the key-hole of the door (upright image). In the indirect 
method (inverted image) the light is thrown into the eye as before, 
but a double-convex lens, held between the thumb and index-finger, is 
interposed in front of the eye under examination, the hand being sup- 
ported by the little finger resting on the patient's forehead. In this 
way the focus can be readily adjusted. 

The simplest appliances suffice for such ophthalmoscopic examina- 
tion as may be required in ordinary clinical work. A small kerosene- 
oil lamp will furnish the light, or, in the absence of this, a candle even 
may be utilized for the purpose. Although such an examination will 
not be sufiicient for any important scientific purpose, it will afford 
more or less valuable insight into the condition of the intracranial 
organs, and suggest the course for future and more accurate investi- 
gation. 

The changes occurring in the retina or the " eye-ground " will be 
mentioned hereafter in connection with the maladies of the brain. 

Impairment of vision, amblyopia, amaurosis, hemiopia, diplopia, 
etc., alterations of the accommodation, deviations of the ocular globe 
from paralysis or spasm of the eye-muscles, the size and sensitiveness 
of the pupil, may be symptomatic of intracranial disease, and will be 
discussed in their proper relations. 

Otological examinations are necessary in all cases of cerebral dis- 
ease, whether or not the ear appears to be directly affected. It has 
already been stated that the condition of the intracranial circulation 
may be ascertained by an inspection of the membranum tympani. 

The hearing power can be measured by the ticking of a watch, by 
the tuning-fork, and by the voice. The distance from the ear the 
tick of a watch can be heard by the normal individual, is the standard 
with which the hearing power is to be compared. For example, if the 
w^atch-tick is audible by the normal ear at a distance of six feet, and 
by the diseased ear at one foot, the hearing power would be stated 
as = \. The voice is a more accurate measure, and the hearing should 
be tested by distinct tones, and by whispering at a specified distance. 
The tuning-fork (of the note C) is used more especially to determine 
the condition of the auditory nerve, and is placed in contact with the 
incisor teeth or forehead. If the patient is deaf to the watch-tick and 
voice, he may still hear the tuning-fork, showing that the difficulty is 
in the sound-conducting apparatus, and not in the nerve, which yet 
transmits the sound vibrations. 

The apparatus required for the investigation of the auditory com- 
plications in cerebral diseases is, besides those mentioned above, a 
suitable ear speculum, and a concave mirror with a central hole, and 
attached to a convenient handle with a universal joint. 



568 



DISEASES OF THE NERVOUS SYSTEM. 



The condition of the hearing power comes into relation to various 
intracranial diseases, such as tumor, abscess, meningitis, etc. Lesions 
of certain parts of the ear cause symptoms of cerebral disease — for 
examples, Meniere's disease or labyrinthine vertigo, etc. 

The electrical reactions of the auditory nerve as determined by 
the polar method have some diagnostic value. 

The sense of taste may be studied by placing sapid substances on 
the tongue, and noting the time when their character is appreciated, or 
the diminution in acuteness or the entire absence of the sense. The 
tongue should be well protruded, and the eyes closed. Then, by 
means of a small spatula, or brush, the substance to be tested is placed 
on that part of the tongue supposed to be affected, and is allowed to 
remain until contact with the nerves is assured. Salt, sugar, quinine, 
and vinegar may be used to determine the appreciation of the saline, 
sweet, bitter, and acid sensations respectively. 

For the electrical reactions, see post. 

Spinal Cord and Nerves. — The examination of this part of the 
nervous system includes sensibility^ motility, and the reflexes. 

Sensibility. — In the absence of special contrivances, sensibility may 
be tested by the simplest means. With a needle-prick, pinching the 




Fig. 45, — ^sthesiometer. 



skin, pulling on hairs, the presence or absence of common sensation 
can be ascertained, and differences noted by comparing symmetrical 
parts. The faradic current is the best mode of ascertaining the ab- 



CLINICAL EXAMINATION. 



569 



sence of the sense of pain {analgesia). In testing in this way, tlie 
skin is carefully dried, and some drying powder (infant powder will 
answer) is dusted over the surface to remove all moisture, so that the 
current may be limited to the skin. A metallic electrode of small size 
is then passed over the affected area and the neighboring normal integ- 
ument. The limits of lessened or absent sensibility to pain are, in 
this way, exactly indicated, and can be marked out. 

The tactile sense is best studied by means of the oesthesiometer, an 
instrument originally devised by Sieveking.* The most convenient 
form of this instrument is that suggested by Hammond, and shown in 
Fig. 45. It consists of a pair of dividers, to one arm of which a scale 
is attached for indicating the distance of the points apart. 

Works on physiology contain tables exhibiting the relative acute- 
ness of the tactile sense of various areas. A few of these may be 
mentioned as a guide. The points of the sesthesiometer can be distin- 
guished as two, at a distance apart — 

On the tip of the tongue of '5 line. 

Palmar surface of index-finger 1 " 

End of the nose 3 lines. 

Palm of the hand 5 " 

Back of the hand 8 " 

Forehead 10 

Back of the foot 18 " 

Front of the thigh 30 " 

Several circumstances affect the results : attention and practice on 
the part of the patient increase the acuteness. When the points are 
separated transversely to the direction of the limb, they are more 
readily perceived than when placed longitudinally ; also, when put on 
one after the other, and when the instrument is moved along the 
surface. 

It is necessary, to secure accuracy, that the patient do not guess ; 
that the points of the instrument be blunted, so that pain may not 
interfere, and that the temperature of the compass be that of the 
body, so that the impression of heat or cold may not increase the 
readiness of perception. 

The sense of temperature may be ascertained by the application of 
hot and cold bodies. Test-tubes containing cold and hot water at a 
known temperature can be put on the affected regions, and the acute- 
ness of perception compared with that of normal parts. 

AUochiria is a peculiar state in which the patient is unable to say 
on which side he has been touched, or refers the sensation to the 
wrong side. 

The sense of pressure and of weight is determined by placing 



* "The British and Foreign Medico-Chirurgical Eeview," January, 1858, p. 251. 



570 



DISEASES OF THE NERYOUS SYSTEM. 



weights on the part to be tested, superimposed, so that the least 
difference can be noted. Eulenburg* has invented for this purpose 
an instrument called the harcesthesiometer^ which is a spring having a 
graduated scale attached, on which are registered varying degrees of 
pressure. Ordinary brass weights, or bits of metal of definite weight, 
can be used for this purpose. They must be sufficiently varied to 
permit a nice discrimination between the sense of the normal and of 
the diseased part. 

Rate of Conduction of Sensory Impressions. — In diseases charac- 
terized by impaired sensibility, the rate at which impressions move 
to affect the sensorism is below the normal, and when hypersesthesia 
exists it may be above. In some cases the retardation may be suffi- 
cient to be recognized by ordinary means, but usually very delicate 
apparatus is necessary to determine the time. The various modes of 
sensibility may be interrogated in turn — touch, pain, taste, vision, and 
hearing. 

Motility. — The motor mechanism to be studied embraces the 
voluntary and the automatic. 

The gait of the patient should be carefully observed — in walking, 
running, standing on leg, etc. The movements of the hands in writ- 
ing, in touching the tip of the 
nose with the eyes closed, in 
buttoning clothing, etc., should 
be watched, and deviations 
from the normal noted. Weak- 
ness of the hands can be meas- 
ured by means of the dyna- 
mometer (Fig. 46) ; and by 
the dynamograph (Fig. 47), 
tremors, unsteadiness, early 
fatigue of the muscles, may be represented graphically. In using the 
dynamometer the spring is grasped in the hand, and the whole 
strength that can be put forth is measured on the graduated scale of 
the instrument. 

The automatic movements to be observed are those of the iris, of 
the respiration, and of walking. The mechanism of locomotion is 
governed by a voluntary and automatic regulator. The effect of dis- 
ease in this locomotive apparatus is seen in the character of the gait. 
For example, the gait of ataxia, the reeling movement in disease of 
the cerebellum, and the ataxia and reeling combined in affections of 
the peduncles of the cerebrum. 

Electric Excitability. — In determining the state of the voluntary 
muscles, both faradic and galvanic excitation must be employed. In 
electrical stimulation we possess the best means of ascertaining the 
* "Lehrbuch der functionellen Nervenkrankheiten," etc., Berlin, p. 17. 




Fig. 46. — Dynamometer. 



CLINICAL EXAMINATION. 



571 



state of the muscles. The applications of the electrodes are labile and 
stabile, direct and indirect — labile, when the electrode is moved over the 
surface under examination ; stabile, when kept in one position ; direct, 




when the electrodes are applied to the muscle to be tested ; indirect, 
when the muscle is stimulated through the motor nerve supplying it. 

When the muscles are healthy, the weakest current that can induce 
a muscular contraction will have an equal effect whether the motor 
nerve or the muscle be stimulated. In using the faradic current for 
determining the state of the voluntary muscles, only the weakest cur- 
rent that will cause contraction should be used. An increase in the 
readiness of response may be noted ; more frequently there ensues a 
quantitive decline, and it is found that not only are stronger currents 
required to bring about a contraction, but that with a current of 
definite strength the contraction j^roduced is feebler than in health. 

The excitability to the faradic current may entirely disappear, and 
no strength of current cause any contraction. 

In using the galvanic current, it must be remembered that mus- 
cular contractions ensue on opening and closing the circuit. There is 
a well-defined law of muscular action under the stimulus of the gal- 
vanic current ; it is called the normal formula, and the method by 
which it has been ascertained is designated the joo/ar ?7?e^Aoc?. Certain 
symbols in imitation of the chemical have been agreed on as a means 
of giving ready and precise expression to the data. The polar method 
consists in the application of the pole, the reactions to which are to be 



572 



DISEASES OF THE NERVOUS SYSTEM. 



determined, to the nerve or muscle, while the other rests on any 
indifferent point, as the sternum, thigh, etc. Closing the current by 
the application of the anode is anodal closing, and is represented 
by the symbol AnS (Schliessimg, closing) ; anodal opening is AnO 
(Oeffnunff, opening). The cathodal closing and opening are repre- 
sented by the symbols KS {Kathode) and KO respectively. Mus- 
cular contraction has for its symbol Z {Zuckung^ contraction) ; z for 
a weak contraction, Z' for a strong contraction, and Te a tetanic 
contraction. 

It is to be noted that the cathode has greater excitant power than 
the anode, and acts more energetically on closing the circuit, whereas 
the anode is more powerful on opening the circuit. 

When the motor nerves are stimulated the reactions are as follows : 
In the lowest degree, the weakest current that will cause a contraction 
is the cathodal closing contraction, KSz, the anode causing none. In 
the intermediate degree, the cathode causes a closing, but no opening 
contraction, while the anode induces both an opening (AnSz) and a 
closing (AnOz) contraction. In the highest degree, the current causes 
tetanic cathodal closing, KSZTe, and a feeble cathodal opening, KOz, 
while there are decided anodal closing and opening contraction, AnSZ, 
AnOZ. 

Such are the results of the stimulation of motor nerves and mus- 
cles in the normal state, with the poles — the polar method — and hence 
the phrase, the normal formulm. These reactions are variously al- 
tered in disease, but the manner and degree of change will be defined 
hereafter, under the head of the symptomatology of the several affec- 
tions concerned. 

The Reflexes. — To every reflex action the following mechanism is 
necessary : A point of perception of the impression or irritation ; 
afferent fibers of communication ; the center ; efferent fibers for trans- 
mitting the reaction outwardly. The reflexes may be deranged in 
two ways : they may be heightened or exaggerated — reflex hyper- 
hinesis ; they may be wanting — reflex akinesis. The cutaneous re- 
flexes are those due to irritation of certain parts of the integument, 
followed by muscular contractions in areas anatomically associated 
therewith. They have, consequently, a high degree of significance, 
and are of great importance as a means of ascertaining the condition 
of the spinal centers. The deep reflexes consist of muscular contrac- 
tions, caused by percussion of the muscles or of their tendons. They 
have even higher significance than the cutaneous reflexes. 

The eye reflexes to be observed are the closure of the lids on irrita- 
tion of the conjunctiva, and contraction of the pupil on exposure to 
the light. The movements of the iris may be studied as follows : 
Closing one eye, the outspread hand is passed in front of the other 
eye. The shadow thus caused sensibly affects the healthy iris. The 



CL^aCAL EXAMIXATION. 



573 



rate and degree of movement, or the absence of movement, should be 
noted. 

The palmar reflex consists in contraction of the fingers on tickling 
the palm, but this can be seen only in infants, or in adults during 
sleep or unconsciousness, since the brain in activity exerts a control- 
ling inhibitive influence on the spinal reflexes. 

The reflexes of the scapula, of the erector spinal muscles, of the 
epigastrium, and of the abdominal muscles, are all produced in the 
same way — namely, by stimulation of the skin of these regions respect- 
ively, and they all depend on a normal condition of the afferent and 
efferent nerves, and of the center, for their eflicient action. 

The cremaster reflex is that drawing up of the testicle which is 
seen when the skin on the inner side of the thighs is irritated, and the 
gluteal when the skin of the buttocks is duly excited. 

The plantar reflex, like the palmar, is produced by tickling the 
skin of the sole, and is seen in perfection when disease above cuts off 
the dorso-lumbar enlargement from the inhibition exerted by the 
brain. 

The value of the reflexes has been carefully investigated by 
Knapp,* with the following results : 

"Absence of the plantar or cremaster reflex is usually pathologi- 
cal, depending on a direct lesion of the reflex arc or some cerebral 
disturbance. Absence of the other cutaneous reflexes is not necessarily 
pathological." 

The Deep Reflexes— The Knee Phenomenon— The Knee-Jerk. — The 

clonic movements produced by percussion of certain tendons have 
considerable pathological significance. If, when the knees are crossed, 
the patellar tendon is struck a smart blow with the ulnar side of the 
extended hand, or with the percussion hammer, a sudden extension of 
the foot takes place, caused by contraction of the thigh extensor mus- 
cles. This is called the "knee-jerk," and in health is very rarely 
absent. The explanation of this phenomenon is not yet agreed on, 
but by most observers it is regarded as a reflex. Although opinions 
may differ as to its nature, there can be no question of the value of 
this sign. In certain states of disease the knee-jerk is present in an 
exaggerated degree ; for example, when the cerebral inhibitory in- 
fluence is withdrawn by disease of the pyramidal tract ; when an 
irritative state of the gray matter or of the efferent and afferent 
nerve fibers exists. The knee-jerk is absent whenever there are de- 
structive lesions in any part of the reflex arc, as in posterior spinal 
sclerosis, in disease of the anterior cornua, and of the efferent fibers of 
the anterior roots, and when the inhibitory action of the cerebrum is 
increased. 

* " Observations on the Cutaneous and Deep Reflexes." By Philip Coombs Knapp, 
A. M , M. D. (Harvard). "The American Journal of the Medical Sciences," April, 1885. 



6Y4 



DISEASES OF THE NERVOUS SYSTEM. 



The anlde clonus is another significant pathological sign, the pres- 
ence of which can be made manifest in healthy persons only after 
preparation which has aptly been termed sensitizing. To induce this 
"sensitized" condition in healthy individuals, the leg is flexed on the 
thigh at an acute angle, the weight of the leg resting on the ball of 
the great toe, the heel raised from the floor. If now the top of the 
knee be struck a smart blow with the edge of the hand, and some 
voluntary motion be given to the limb in this position, a rhythmical 
movement, clonic spasm — the ankle clonus — will then go on independ- 
ently. This movement is due to clonic contractions of the gastroc- 
nemius, resulting in alternate elevation and depression of the knee 
and heel. In certain diseases, as lateral sclerosis, the ankle clonus is 
produced without preparation. If the heel is held in the operator's 
left hand, while the right puts the foot into the position of dorsal 
flexion by pressure on the ball of the great toe, the ankle clonus will 
then appear on tapping smartly the top of the knee. The clonus con- 
sists in rhythmical contractions and relaxation of the muscle, and con- 
sequent elevation and depression of the toes. 



CEREBRAL HYPEREMIA. 

Definition. — Cerebral hyperwtnia, or cerebral congestion, is a mal- 
ady characterized by an increase in the amount of blood in the brain. 
The hypersemia may be arterial, or active; venous, ov passive. 

Causes. — Any condition diminishing the amount of arterial blood 
in other parts will divert a larger quantity to the cranial cavity : com- 
pression of the abdominal aorta, ligation of an important artery, are 
examples. The suppression of an habitual discharge of blood — as that 
of haemorrhoids, for illustration — is alleged to produce the same effect. 
Cerebral congestion occurs in the cold stage of an ague, and is also 
produced by the application of cold to the surface of the body. Pro- 
longed intellectual effort, insolation, or sunstroke, protracted wakeful- 
ness, over-indulgence in alcoholic beverages, and the use of such nar- 
cotics as belladonna, are supposed to induce congestion of the brain. 
Hypertrophy of the heart, fullness of the general vascular system, 
and general plethora, are also alleged to have this effect, but grave 
doubts may well exist on this point. Passive congestion is produced 
when there is an obstacle to the return of blood from the cranial 
cavity, as when the superior vena cava and the jugular are com- 
pressed by intra-thoracic or cervical tumors, or when the venous system 
is overfilled by mitral or tricuspid disease. Venous stasis is also caused 
by atheromatous degeneration of the arterial tunics, feebleness of the 
cardiac contractions, and lowered vascular tonus. 

Pathological Anatomy, — There are no structural changes beyond 



CEREBRAL HYPEREMIA. 



575 



an increase in the amount of blood, the displacement of a correspond- 
ing amount of cerebro-spinal fluid, and mechanical compression of the 
cerebral matter. The veins of the dura mater are distended, but still 
more those of the pia mater and choroid plexus. The sinuses are 
also overfilled. The convolutions are somewhat flattened, and the 
perivascular lymph-spaces are closed by the approximation of their 
walls. On section, more blood than normal flows out of the divided 
vessels, and the puncta vasciilosa are more numerous. If the hyper- 
semia is of long standing, or if repeated attacks have occurred, the 
changes are more pronounced. The veins enlarge and become vari- 
cose, and small arteries previously invisible come into permanent view, 
and aneurismal dilatations form on the arterioles. There may be mi- 
nute extravasations and capillary haemorrhages, the evidence of which 
is afforded in old cases by pigment deposits and blood-crystals in the 
lymph-spaces. Transudations of serum may occur in the subarach- 
noid spaces and in the ventricles, and also in the perivascular sheaths, 
whence it follows, in old cases, that permanent dilatation of these 
spaces may have occurred, producing the etat crible. 

Symptoms. — There are three well-marked forms of cerebral hyper- 
semia — the light, the severe, and the apoplectic (Jaccoud). In the light 
form the onset is gradual, and among the first symptoms is headache, 
which is soon followed by characteristic signs : the headache is dull 
and heavy, with occasional sharp, lancinating pains, increased by mo- 
tion or sudden shocks, or by light and sound ; there is inaptitude 
for any mental effort, and the attempt to exercise the mind causes a 
sense of cerebral exhaustion ; there is singing in the ears, with other 
subjective noises ; the conjunctivae are injected, the retina is sensitive 
to light, and there are flashes of light and moving objects before the 
eyes ; the sleep is fitful and unrefreshing, and disturbed by dreams of 
a terrifying kind ; vertigo occurs, and the muscular movements are 
uncertain and fatiguing ; the sensations are disordered, and numbness 
and tingling are felt in the extremities ; the stomach is uncertain, and 
nausea is often experienced ; and the heart is exceedingly irritable, 
the pulse rising considerably with the least mental or physical effort 
or emotional excitement.* The severe form may develop out of the 
light, or it may come on without any prodromic symptoms. As com- 
pared with the light form, we find the headache is more intense ; the 
special senses are more irritable and intolerant of light and sound ; 
the mind more disturbed, ideation more confused, illusions and hallu- 
cinations occurring ; the wakefulness more obstinate , and complete ; 
the motor functions more excited, the movements more irregular and 
uncertain, jactitations appearing ; the sensory functions are more per- 
verted ; besides the headache, are neuralgic pains, especially in the 

* Hammond, " Cerebral Ilypertemia," p. 48. 



576 



DISEASES OF THE NERVOUS SYSTEM. 



fifth, numbness and tingling being felt in the extremities ; the vertigo 
is more decided, the upright position being maintained with difficulty, 
and all coordinated and combined acts being executed with difficulty ; 
the action of the heart is more excited, the pulsations irregular and 
rapid, and the least effort sending the beat up many times ; the head 
is more decidedly warm, the eyes more suffused, more deeply injected, 
the eyelids more swollen ; the stomach is more disordered, and nausea 
and vomiting are excited by effort of the mind, or by attempt at close 
attention. The symptoms indicate the approach of acute maniacal 
excitement, or acute inflammation ; but the mind, although occupied 
by illusions and hallucinations, is still able to correct them or reason 
correctly about them, and the febrile condition does not yet exist. 
The symptoms may subside in a day or two, and health be restored 
in a few days, or, the case unrelieved may then pass into the stage of 
depression ; torpor succeeding to exalted activity, drowsiness to wake- 
fulness, coma to delirium. In adults, convulsions rarely occur in the 
course of the severe form, but are usual in children. 

In the apoplectiform variety of cerebral congestion, the patient may 
suddenly pass into unconsciousness, with the usual phenomena attend- 
ing the apoplectic attack ; there is complete muscular relaxation, in- 
voluntary evacuations may occur, but the reflex movements are not in 
abeyance, and in some minutes or hours the patient returns to con- 
sciousness, somewhat confused, however, and does not entirely recover 
for some days. Without losing consciousness, he may suffer con- 
fusion of mind, extreme vertigo, have defects of speech, or an entire 
loss of memory for words, numbness, tingling, and paresis of the mem- 
bers, nausea and vomiting, etc., also coming on suddenly, and dis- 
appearing after some hours and days without permanent disability. 
The symptoms belonging to the venous or passive form of hyperaemia 
are much less pronounced, although in some respects similar. There 
is headache, but a sensation of heaviness and dullness rather than 
acute pain ; the eyelids are swollen and puffy, but the conjunctivae are 
not injected ; the superficial veins are full, but the scalp is cool ; sing- 
ing in the ears and impaired hearing are noted ; vision is dull, and 
floating objects are seen before the eyes ; the mental operations are 
dull and confused ; somnolence passing into stupor, without continuous 
normal sleep, dreams, illusions, and sudden startings in the sleep, occur 
from time to time. On ophthalmoscopic examination, there are ascer- 
tained to be an enlargement of the retinal veins, more or less swelling 
of the optic disk, and vessels before invisible come into view. When 
the congestion of the brain is of the passive variety, the retinal veins are 
unduly enlarged and tortuous. Observations on the drum membrane 
disclose increased vascularity of this organ, which has intimate con- 
nection with the intra-cranial circulation. The superficial temperature 
of the head is elevated in active hyperemia, but is not affected in the 



CEREBRAL HYPEREMIA. 



577 



passive form. Surface thermometers and Lombard's thermo-electric 
pile are employed to ascertain the temperature of the scalp. In any 
case there will be but slight rise of the thermometer ; hence, any con- 
siderable elevation should awaken suspicion of inflammatory action. 

Course, Duration, and Termination— The light form may terminate 
in a few hours or days, under appropriate treatment, to recur from time 
to time, it may be ; or it may continue with fluctuations in the severity 
of the symptoms for months and years. A cure readily results, if the 
causes cease to operate and the right management is instituted. If 
the hyperaemia continue, other morbid conditions will arise out of it. 
The severe form has a variable duration. A cure may be effected if 
right treatment is instituted early enough, but structural alterations will 
not be long delayed, and mental derangement will occur at an early 
period, or a cerebral haemorrhage may take place. The apoplectiform 
variety may terminate in health or in cerebral hasmorrhage, according 
to the method pursued and the nature of the causes. Attacks of this 
nature may precede cerebral haemorrhage, as the author has several 
times witnessed, but they are not often repeated until the haemorrhage 
takes place. The passive form pursues the fortunes of the lesions 
causing it, and hence the duration is very variable and the course pro- 
tracted. 

Diagnosis. — The symptoms being due to disturbances of the intra* 
cranial circulation, the diagnosis rests on the absence of symptoms in- 
dicating structural lesions — notably the absence of fever, the wide- 
spread bilateral diffusion of the symptoms, and the fugitive character 
of the attacks. It may be confounded with delirium tremens, epilepsy, 
apoplexy, stomachal vertigo, etc. As respects delirium tremens, the 
distinction rests on the habits, the previous history, and the severity 
and persistence of the symptoms in this disease. The attack of epi- 
lepsy is preceded by a cry ; then come pallor of the face, stertorous 
breathing from tetanic fixation of the muscles of respiration, cyanosis, 
and general convulsions. Children with congestion of the brain may 
have such convulsions as a symptom, but the history preceding and 
succeeding is very different in the two maladies. The apoplectic form 
is distinguished from apoplexy by the persistence of the reflex move- 
ments, by the absence of conjugate deviation of the eyes, and by the 
early recovery without hemiplegia. Stomachal vertigo is preceded by 
attacks of indigestion, and is accompanied by the conditions of syncope 
and anaemia, instead of hyperaemia. 

Treatment.— Causes of the hyperaemia should cease, if possible. 
If it be the active form, the head should be elevated and cold applied, 
the feet being immersed in hot mustard-water. To withdraw tempo- 
rarily from the circulation some of the blood, a ligature should be ap- 
plied around the thigh or thighs for a time, alternating the application 
of the ligature to prevent injury. Leeches may also be applied to the 



578 



DISEASES OF THE NERVOUS SYSTEM. 



mastoid process, or cups to the neck. In the apoplectiform variety- 
venesection is advisable, as this is the most expeditious means of dimin- 
ishing the intra-cranial blood-pressure. A brisk purgative is also an 
excellent expedient, relieving by acting as a derivative and by lessen- 
ing vascular tension. The intra-cranial blood-pressure can also be low- 
ered by the exhibition of veratrum viride, aconite, bromide of potas- 
sium, ergot, etc. These remedies are sufficient in the light form, but 
in the severe form a combination of the various means of treatment 
will be necessary. The treatment of the passive form is a part of the 
treatment required in the condition producing the hyperaemia, and need 
not now be discussed. The strictest attention must be paid to the 
diet and mode of life. An abstemious life — the diet consisting of 
fruit and vegetables chiefly — and early hours and the avoidance of all 
forms of excitement have prolonged life for many years, when an early 
demise was threatened by cerebral hyperaemia. Especially should 
alcoholic stimulants and the powerful emotions excited by speculations 
of all kinds be avoided. Such mild stimulants as tea and coffee even 
should be abandoned. In making these suggestions the author wishes 
his readers to note that he regards protracted rest to the mind as often 
injurious, and that light mental occupation is preferable to an entire 
disuse of the faculties. 

CEREBRAL ANEMIA. 

Definition. — By cerebral anaemia is meant a lessened amount of 
blood in the brain. It may be general or partial: in the former the 
diminished supply of blood affects the whole organ ; in the latter a 
particular district is deprived of its blood by the occlusion of a vessel. 
It is the general form of cerebral anaemia to be considered here. 

Causes. — The most perfect type of cerebral anaemia is that produced 
by large loss of blood. Our knowledge of this condition has been ren- 
dered the more accurate by the experimental study of the subject in ani- 
mals.* The effects of loss of blood on the functions of the brain are 
seen after severe haemorrhage, as post-partiim haemorrhage, unavoid- 
able haemorrhage, menorrhagia, metrorrhagia, etc. Chronic wasting 
diseases, by the constant losses of nutrient material, induce cerebral 
anaemia. Phthisis, chronic dysentery, suppuration, and prolonged lac- 
tation, belong to this category. Maladies which impair the power to 
produce nutrient material, affecting the primary and secondary assimila- 
tion, will also cause anaemia of the brain. To this state as it occurs in 
infants was applied the term hydroceplialoid by Marshall Hall, who 
first demonstrated the important fact that a condition supposed to be 
due to inflammation was really the product of anaemia. Under the 
influence of shock, by powerful mental or moral emotions, a sudden 
* Kussmaul and Tenner, " Sydenham Society's Translation." 



CEREBRAL ANJEMIA. 



579 



contraction of the intra-cranial vessels occurs, and syncope, with loss 
of consciousness, ensues. Feebleness of the heart induces ansemia of 
the brain — a fact well exemplified in the sudden pallor and faintness 
experienced by convalescents on rising up after long decubitus ; also 
in the case of those who suffer from weak heart, fatty heart, or ob- 
struction at the aortic orifice, etc. 

Pathological Anatomy. — The morbid changes are very simple. 
The amount of blood is below the normal, and the vessels are less 
full. The appearance of the brain is pale and exsanguine, and on 
transverse section of the hemispheres there are no bloody points. 
The subarachnoid spaces and the ventricles contain a good deal of 
fluid, and the perivascular lymph-spaces are also well filled with fluid, 
for, as the vessels contain less blood, the cerebro-spinal fluid increases ; 
while in hyperaemia the distention of the vessels forces the fluid out, 
closes the lymph-spaces, and flattens the convolutions. The opposite 
state obtains in anaemia : the brain is pale, white, and moist ; the ves- 
sels small, the lymph-spaces large. In partial anaemia, other factors 
are concerned, and hence the local conditions differ. 

Symptoms. — There are two distinct forms : acute, or sudden ; 
chronic, or light. Venesection ad deliqincm animi furnishes a com- 
plete picture of the first : the face grows deadly pale, the lips white, 
the pupils dilate, the action of the heart becomes very feeble, the pulse 
small, a cold sweat breaks ouc over the body, ringing noises sound in 
the ears, surrounding objects appear dim, and a mist gathers before 
the eyes ; voices are heard in the distance, and the words are unintel- 
ligible, everything fades suddenly out of consciousness, and the patient 
falls as if lifeless, respiration having ceased, and the heat-beart scarcely 
continuing. There is complete muscular resolution, but in an instant 
the eyelids begin to tremble, the muscles of the lips and face twitch, 
and a general convulsion follows. The syncope, which is merely a 
fainting-fit, does not proceed any further than suspension of conscious- 
ness, and in a short time the respiration begins, the heart-beat grows 
stronger, the patient opens his eyes, looks around with a dazed expres- 
sion, and asks what has happened ; he tries to get up, and finds him- 
self very weak, but in a short time the bodily vigor is entirely restored. 
The convulsions of cerebral angemia are due to two factors : to an ab- 
normal excitability of the " spasm-center " ; to the circulation of black 
blood through this spasm-center. In the slow, habitual, or chronic 
anaemia, the condition is that of depression of function. The brain, 
inadequately supplied with nutrient material, functionates imperfectly ; 
the special senses are both irritable and depressed — the sight is dull 
(amblyopia), and light is painful to the eyes ; hearing is obtuse, there 
are subjective noises in the ears, tinnitus, etc., and loud sounds are 
distressing ; the mental operations are slow and confused, and there 
may be illusions, hallucinations, maniacal excitement, etc. (puerperal 



580 



DISEASES OF THE NERVOUS SYSTEM. 



mania, insanity of lactation, etc.) ; muscular movements are excited, 
or depressed and feeble, tremulous or incoordinate ; the sensory func- 
tions are similarly affected — there may be excitement or depression, 
neuralgic pains, numbness, prickling, tingling, or anaesthesia ; vertigo 
is nearly always present, and consequent uncertainty of movements ; 
headache is also commonly present, and may be a sense of heaviness 
or oppression, or, more frequently, acute pain ; exertion causes great 
fatigue, and syncopal attacks are easily induced ; the action of the 
heart is weak, and rapid action is excited by the least movement ; 
and the sense of faintness is usually accompanied by nausea. In the 
form of cerebral anaemia, known as hydrocephaloid, the child is ex- 
hausted by a wasting malady ; its surface is cool, skin pale, the pulse 
quick and weak, the eyes are half closed, sunken, and surrounded by 
broad, dark areolae, the fontanelle is concave, the head cool ; there is 
much fretfulness, although there is a somnolent state ; the stomach 
is irritable, the bowels relaxed. 

Course, Duration, and Termination. — The acute form, so far as the 
immediate attack is concerned, lasts a few minutes only, but this is 
merely a symptom of a long-established anaemia of the brain. The 
chronic form has an indefinite duration, and pursues a varying course 
according to the management and the nature of the causes. The 
termination is usually in restoration to the normal state, if the treat- 
ment be suitable. So important are the changes in the vessel-walls in 
ana3mia, that we should not overlook the gravity of any case that has 
continued a long time. Furthermore, as various intercurrent maladies 
may develop, prognostic opinions should be expressed with caution if 
the anaemia has persisted. 

Diagnosis. — As cerebral hyperaemia presents many symptoms in 
common with cerebral anaemia, the diagnosis of these affections may 
be confused, but attention to a few points ought to conduct to right 
conclusions. The history of the causes, the appearances of anaemia, 
and the depression of the circulation, will indicate the nature of the 
case. The use of the surface thermometer, or thermo-electric pile, to 
ascertain the temperature of the scalp, is necessary, for in anaemia the 
temperature is rather below than above normal, but in hyperaemia the 
opposite condition obtains. Ophthalmoscopic inspection of the retina 
and otoscopic inspection of the drum membrane should be made, to 
ascertain the character of the circulation : in hyperaemia the retinal 
vessels are abnormally full and the drum is red and injected, whereas 
in anaemia the retina and drum membrane are pale and comparatively 
bloodless. 

Treatment. — The recumbent posture and stimulation ot the nares 
with ammonia are the only measures necessary in the treatment of 
syncope. When alarming depression is due to haemorrhage, besides 
the measures necessary to stop the loss of blood, anaemia of the brain 



OCCLUSION OF THE CEREBRAL VESSELS. 



581 



is to be overcome by depression of the head and elevation of the 
limbs, by the administration of alcoholic stimulants, by the subcutane- 
ous injection of stimulants, by the intravenous injection of ammonia, 
and by transfusion. The chronic form of cerebral anaemia is to be 
arrested by stopping the sources of waste, by the use of iron and the 
phosphates, and by judicious alimentation. The best results are ob- 
tained by the administration of a stimulant to the cerobro-spinal axis 
(strychnine) and a chalybeate tonic. Arsenic is often highly service- 
able in cerebral anaemia, in combination with iron. For the maniacal 
delirium of cerebral anaemia, the hypodermatic injection of morphine 
is of the greatest value. When there is associated with this delirium 
a high degree of motor excitement, atropine or duboisine should be 
combined with the morphine. 

OCCLUSION OF THE CEREBRAL VESSELS. 

Definition. — Under this term are included all lesions which occlude 
or block the vessels, thus causing anaemia of some part or parts of the 
brain. The occlusion may form in a cerebral vessel, or may be pro- 
duced by an embolism conveyed thither from any pa;*t of the vascular 
system. Under this term must be comprised the remote as well as the 
immediate results of occlusion. 

Causes. — The factors chiefly concerned in the occlusion of intra- 
cranial vessels are thrombosis and embolism. Chronic endarteritis and 
slowing with weakening of the blood-current are the causes of throm- 
bosis. The changes in the arterial tunics consist in atheromatous and 
calcareous degeneration ; the lumen of the vessel is gradually narrowed 
by the deposition of new material, and the intima is roughened. The 
propulsion of the blood is hindered by weakness of the heart's action, 
and by diminished elasticity of the walls of the arteries, due to the 
atheromatous changes in the tunics. When the disease in the walls 
of a cerebral, vessel reaches a certain point, coagulation of the blood 
takes place and an occlusion (autochthonous thrombosis) is thus effect- 
ed. The formation of a thrombus is also favored by the condition of 
the blood itself. In chronic wasting diseases, the relative proportion 
of fibrin in the blood being much increased, coagulation is promoted 
accordingly. An autochthonous thrombus may form in a vessel whose 
lumen had been obstructed by the pressure of a tumor. 

Emboli consist of bits of fibrin, exudations, or concretions, which, 
formed at some distant point and carried into the circulation, are 
deposited in the brain. The most usual source of emboli is endocar- 
ditis, either of the ulcerative variety or of the chronic form with its 
polyp-like excrescences, or fibrin vegetations. According to the ob- 
servations of Bertin, the emboli come from the left auricle, four times ; 
from the left ventricle, twelve times ; from the aortic valves, ten 



582 



DISEASES OF THE NERVOUS SYSTEM. 



times ; from the mitral, twenty-four times. These figures agree with 
the usual experience on this point. Cardiac emboli are also produced 
in the following way : olots form, especially in the auricle, when the 
heart is weakened by myocarditis, fatty degeneration, uncompensated 
valvular lesions, and such chronic wasting diseases as cancer and tu- 
berculosis. Such clots, subsequently pulverized by the cardiac move- 
ments, are carried into the circulation. Emboli may also be derived 
from aortic aneurism, from syphiloma of the great vessels, etc. 

Pathological Anatomy. — Owing to its position at or near the summit 
of the arch of the aorta, the blood-current from the aortic orifice is di- 
rected to the left common carotid, so that an embolus loosened from 
the heart naturally enters this vessel, and its prolongation within the 
cranium, the Sylvian artery. It necessarily follows from this that the 
left side is usually obstructed. It rarely happens that an embolus en- 
ters the vertebral arteries. Sometimes the embolisms are multiple, and 
enter the vessels on both sides, or are lodged in different places on the 
left side. As certain vessels are usually occluded, it is important to 
have a clear understanding of the parts supplied by them. The left 
Sylvian artery sends branches to the second and third frontal convolu- 
tions, the anterior and superior portions of the three temporal convolu- 
tions, the island of Reil, the parietal convolutions, part of the external 
and all of the internal capsule, the lenticular nucleus, and most of the 
corpus striatum. It is important to note, further, that the vessels of 
this part of the brain have the arrangement of Cohnheim's terminal 
arteries — arteries without anastomoses — while the vessels of the gray 
matter of the hemispheres, or the cortex, communicate freely with 
each other.* When an artery of the "basal system" is obstructed^ 
either by a thrombus or embolism, an ansemia of the territory sup- 
plied by the vessel at once ensues — either a simple anjemia and white 
softening, or anaemia followed by collateral hyperjemia and cedema. 
The simple ansemia and w^hite or yellowish-white softening occur 
when the blood in the whole extent of the occluded vessel coagulat- 
ing, prevents the backward flow of blood through the capillaries, and 
consequently the collateral hypersemia and oedema. The anaemic tis- 
sue dies or undergoes necrobiosis in consequence of the loss of its en- 
tire nutritive supply. The nerve-tissue elements become disassociated, 
break up into a difiluent granular mass, and are crowded with fat-cells, 
whence the color of the softened tissues assumes a somewhat yellowish 
aspect. Yellow softening is also a stage of the next form. When a 
terminal artery is occluded, and all parts of the vessel beyond the seat 
of obstruction remain pervious, blood flows back through the capilla- 
ries from the nearest artery and vein, until the previously anaemic and 
bloodless district is deeply engorged. Changes now occur in the walls 

* The reader should peruse in this connection the articles on "Arteritis" and on 
" Thrombosis and Embolism." 



OCCLUSION OF THE CEREBRAL VESSELS. 



583 



of the vessels, permitting diapedesis of the red blood-globules. As, in 
the process of softening and disintegration which now ensues, the tis- 
sues are colored by the red corpuscles, the appearances are entitled 
red softening." Minute extravasations occur here and there, from 
rupture of capillaries, and hence, in the midst of a uniform red there 
will be seen the dark points of " capillary apoplexy." These extrava- 
sations may be so numerous as to present the appearance of a cerebral 
hfemorrhage. In from two to four weeks the red softening becomes 
yellow softening in consequence of the transformation of the haemo- 
globulin and the fatty degeneration of the nerve-elements. The soft- 
ening proceeding to another stage becomes " white softening," when 
there . is a milky, or rather creamy fluid, containing, mixed with it, 
masses or particles of broken-down nerve-elements. There is no abrupt 
line of demarkation, but the diseased part shades off into the surround- 
ing healthy part by a fine gradation. 

Symptoms. — There are two well-defined modes of onset : the grad- 
ual, which occurs to thrombosis ; the sudden, or apoplectic, due to 
embolism. The first form, or thrombosis, is a malady of the old ; the 
second form, or embolism, may occur at any period, frequently in the 
young. As, when chronic arteritis of the cerebral vessels exists, a num- 
ber of them may be diseased at the same time, the resulting symptoms 
must necessarily be widely diffused, and, as the disease has proceeded 
to different stages at different points, there may be present, at the same 
time, the symptoms of excitation and depression of function. Head- 
ache, more or less persistent, and of variable intensity, is the earliest 
symptom ; next, alterations of character become evident — the indi- 
vidual grows irritable, morose, and despondent, his mind is easily 
fatigued, and memory is impaired ; at first names, then some unusual 
word, ultimately most words, are forgotten. Occasionally the only 
mental defect observed is loss of the memory for words — amnesia of 
verbal language — which may occur slowly or suddenly, with or with- 
out something of a stroke. After the headache, vertigo comes on, and 
may be occasional and caused by a change of posture, or it may be 
constant when sitting up and when recumbent. Difficulty of locomo- 
tion is experienced, in consequence partly of the vertigo, but chiefly 
because of weakness of a group of muscles or of a member ; more or 
less of senile trembling may be present, or the trembling of muscular 
weakness ; and the movements of the tongue may be imperfect and 
speech hesitating and mumbling. There are two causes for the symp- 
toms just detailed — gradual encroachment on the lumen of diseased 
vessels, whence the blood-stream is lessened, and interference with 
the nutrition of the brain by reason of calcareous degeneration of the 
capillaries. The next point in the morbid complexus is the occurrence 
of a sudden attack, which may or may not be apoplectic. If apoplec- 
tic, the patient falls suddenly into a condition of insensibility, with 



584 



DISEASES OF THE NERVOUS SYSTEM. 



complete muscular resolution. On emerging from such an attack 
there may be hemiplegia ; if right hemiplegia, associated with more 
or less disability of speech, possibly with aphasia. In other cases, 
with equal suddenness, but without any apoplectic seizure, there may 
occur a hemiplegia, or the paralysis may be limited to the arm, or to 
the leg, or to the face ; it may be complete or partial (paresis), and 
with weakness there may be contractions and rigidity. The paralysis 
may disappear quickly, and after an uncertain period may occur again, 
or be succeeded by rigidity and contraction. The disappearance of a 
paralysis under these circumstances means the reopening of the ob- 
structed area to the circulation by collateral channels or anastomoses 
— a condition of things only possible in the cortex. An autochthonous 
thrombus may form in a vessel of the basal system. The final occlu- 
sion of the vessel may be preceded by various prodroraata — by head- 
aches, vertiginous sensations, numbness, tingling, formication, cold- 
ness, muscular cramps, etc. Paralysis may develop slowly, as the 
thrombus slowly forms, or suddenly, with the usual phenomena of 
the apoplectic stroke ; the paralysis is strictly localized and does not 
change, for, the vessels being of the terminal kind, collateral hyperre- 
mia and oedema result, and the affected tissue goes through the pro- 
cess of necrobiosis. When occlusion occurs in this way, the subse- 
quent phenomena are the same as those of embolism. As the embolus 
causing the cerebral mischief comes from some distant point in the 
vascular system, it is obvious that there can be no intra-cranial disor- 
ders produced by it ere it effects a lodgment in the brain. It is evi- 
dent that there must be very considerable variation in the severity of 
the symptoms, according to the importance and the situation of the 
vessel occluded. In a majority of cases the attack is apoplectic — 
there may be for an instant intense headache and dizziness, sudden 
flush or pallor of the face, or the patient may utter a wild cry — he 
falls immediately into unconsciousness, with complete muscular reso- 
lution, or there may be a distinct epileptiform seizure. Instead of un- 
consciousness, the stroke may be nothing more than a severe vertigo, 
with confusion of mind, muscular twitchings on the affected side, and 
vomiting. Vomiting may also occur in the apoplectic form, just as the 
mental confusion is coming on. On recovering from the stroke or 
shock — which is doubtless due to the suddenly produced partial anae- 
mia, effecting at the same moment an immense change in the intra-cra- 
nial blood-pressure — a hemiplegia is found to exist, and it is most fre- 
quently of the right side, owing to the arrangement of the vessels on 
the left side of the brain. Although right hemiplegia is usual, it is 
not invariable : there may be left hemiplegia, or bilateral paralysis, or 
paralysis of the different cranial nerves. Embolism may also affect 
the central artery of the retina, and amaui osis result from the occlu- 
sion. Double optic neuritis arises during the course of all "coarse 



OCCLUSION OF THE CEREBRAL VESSELS. 



585 



organic lesions " of the brain, and hence ophthalmoscopic examination 
is a necessary duty in such cases. The mental functions are variously 
affected. In the slow form of occlusion — thrombosis from chronic 
endarteritis — there is gradual mental failure, beginning in loss of 
memory, and thence the spectacle of senile dementia. In embolism 
the mental faculties are, during the period of coma, entirely sus- 
pended ; if the patient emerge from this with hemiplegia, the mind is 
always enfeebled to a greater or less extent, the language faculty is 
variously impaired, the emotional nature is highly excited, and the 
reason and judgment are clouded. With right hemiplegia from em- 
bolism there is usually associated aphasia, or loss or impairment of 
the faculty of communicating ideas by words or by signs. The hemi- 
plegia involves the tongue and the corresponding side of the face. 
The reflex movements are readily excited in the paralyzed parts. 
When there is embolic obstruction of the basilar artery, the symptoms 
differ somewhat from the description above given. The hemispheres 
are not involved, nor the important parts supplied by the Sylvian 
artery ; there is no apoplectic seizure, nor loss of consciousness, nor 
troubles of the intellectual faculties. There are disorders in vocal 
expression, due to paralysis or ataxia of the muscles of the tongue 
(ataxic aphasia), but vertigo and vomiting are usual symptoms. 

Course, Duration, and Termination. — The course of symptoms refer- 
able to the changes preceding and resulting in thrombosis is essentially 
chronic. Months and years may be occupied in reaching the point of 
coagulation, and other months, even years, may be passed in the para- 
lytic state. When the lesions are of the basal system they are per- 
manent. Although there may be some improvement, which, however, 
does not continue, the members paralyzed remain in the condition at 
which they had arrived after several months. In thromboses the most 
sudden and considerable improvement takes place in paralysis of mem- 
bers, defects of speech, and disorders of sensations, due to disease of 
the vessels of the cortex ; but the probability of the return of these 
lesions, or of the appearance of other lesions, should not be forgotten. 
While the prospect of great immediate improvement is good in such 
cases, the future must be regarded with apprehension. On the other 
hand, in embolic occlusion, the immediate results are more severe. 
Death may be the result of the occlusion of a large vessel within two 
or three days, or longer, the patient never emerging from the coma. 
In other cases the patient arouses from the coma, hemiplegia exists 
with aphasia, the temperature rises a little as the collateral hyperaemia 
and oedema come on, but falls again in a few days, and the case then 
pursues the usual course of localized softening from any cause., Right 
hemiplegia and aphasia, from blocking of the left middle cerebral, may 
occur in youth, early manhood, at any period in fact, and are asso- 
ciated with valvular disease, usually of rheumatic origin. These lesions 



586 



DISEASES OF THE NERVOUS SYSTEM. 



may also be associated with aneurism, with syphiloma, or with ulcera- 
tive endocarditis. 

Diagnosis. — The diagnosis of thrombosis rests on the evidence of 
chronic arteritis — the simultaneous presence of the changes in the 
radial, the color of the hair, the condition of the skin, an arcus senilis ; 
on the variability and diffusion of the prodromal signs, and those of 
the established lesions. Embolism is known by the age of the subject 
(often so at least), by the history of rheumatism, the existence of val- 
vular lesions, by the suddenness of onset without prodromes. 

Treatment. — The author has had remarkable results from the follow- 
ing plan of treatment in thrombosis : Carbonate and iodide of ammo- 
nium (ten grains of the former and five grains of the latter) are given 
three times a day in a suitable vehicle, for several months, usually, the 
object being dual — to increase the action of the heart and arteries, and 
to effect a solution of thrombi forming by maintaining the alkalinity 
of the blood. To postpone and possibly arrest the atheromatous de- 
generation of the vessels, cod-liver oil and the sirup of the lactophos- 
phate of lime are regularly exhibited (a teaspoonful of each) three 
times a day, immediately after meals. The ammonia solution is ad- 
ministered before meals. At the same time these remedies are being 
given, a daily dose (at 10 a. m.) of quinine (five to ten grains) is also 
prescribed, should there be a condition of depression and languor of 
the intracranial circulation requiring it, but the carbonate of ammonia 
is usually sufficient. With this plan is conjoined a suitable regimen — 
a siniple but nutritious diet, moderate exercise, and careful supervision 
of the various excreta. As soon as possible after an embolic obstruc- 
tion has occurred, carbonate of ammonia should be given — very useful- 
ly in the liquor ammonii acetatis — and should be kept up for wrecks. 
The most absolute rest should be maintained, and the diet should be 
light and unstimulating. In a month or two a very light galvanic 
current (from two cups) may be passed through the brain in both 
directions. Quinine is most useful, especially if there be any elevation 
of temperature ; but in all cases it has seemed to the author highly 
useful after some weeks' administration of ammonium carbonate. 

OBLITERATION OF THE CEREBRAL CAPILLARIES. 

Pathogeny. — The capillaries of the brain are occluded by the finer 
particles which readily pass through the larger vessels. In the severer 
forms of acute malarial poisoning small particles of pigment are formed, 
and, entering the cerebral capillaries, lodge, and are known as pigment 
embolisms.'''' Violent delirium, terminating in coma, and sometimes 
convulsions, may result from the occlusions formed in this way. The 
white-blood corpuscles, under conditions not now understood, aggre- 
gate in masses and form emboli. These are probably examples of 



OCCLUSIOX OF THE CEREBRAL SINUSES. 



587 



pyemic change, for such emboli have been formed in connection with 
pyjemia, erysipelas of the face, etc. Emboli, consisting of particles of 
cancerous, septic, or decomposing material— zn/ec^^ue emboli — may also 
be minute enough to pass the larger vessels and occlude the cerebral 
capillaries. In very rare cases the capillaries are blocked by lime salts, 
taken up at some point where disintegration of bone is going on — 
lime-salts emboli. Again, emboli consist of fat-globules which enter 
the blood from the marrow of fractured bones— /a^ emboli. The capil- 
laries of the lungs may arrest them entirely, and hence the most serious 
symptoms are referable to these organs ; but the finest globules may 
pass through the lungs and block some of the cerebral capillaries. As 
the anastomoses between the capillaries are very abundant, it is obvious 
that if the obstructions are but few in number they will be compen- 
sated for. When numerous, there will be produced anaemia, followed 
by the usual changes of necrobiosis, ending in softening. 

Symptoms. — In the case of pigment embolisms occurring during a 
malarial fever, the onset of this malady is announced by intense head- 
ache, vertigo, delirium, sometimes convulsions, and the febrile phe- 
nomena are greatly intensified. If, during the course of facial erysip- 
elas, similar symptoms arise, they may be due to white-corpuscle em- 
bolisms, or, if occurring after a fracture of a bone, may be due to fat- 
embolisms. When the embolisms are not very numerous the symp- 
toms may be less pronounced : there may be dizziness, loss of memory, 
and other mental defects, persistent headache, etc. In any case the 
diagnosis can hardly be more than a fortunate guess. The treatment 
may be conducted on the same basis as that of occlusion of the arteries. 

OCCLUSION OF THE CEREBRAL SINUSES. 

Pathogeny. — Thrombosis is the mode of occlusion of the cerebral 
sinuses, and it may result from venous stasis or from phlebitis. In the 
former case the propelling power of the heart is much reduced, and 
the fibrin of ' the blood increased (hyperinosis) . This condition of af- 
fairs occurs chiefly in children exhausted by long-standing illness ; in 
the cases observed by the author, there had existed an ileo-colitis of 
several weeks. The phlebitis is secondary to some morbid process in 
the neighborhood, most frequently to caries of the petrous portion of 
the temporal bone, and the petrosal or transverse sinus only may be 
attacked, but the purulent phlebitis extends occasionally to the cavern- 
ous sinus and the circular sinus. Next to caries of the bones, the 
most frequent cause of this form of thrombus is erysipelas of the head 
and face, carbuncle of the upper lip or nose, and malignant pustule of 
the lip. The position of the thrombus is determined by the nature of 
the cause : if caries, the thrombus is found in the transverse or petrosal 
or cavernous sinus ; if erysipelas, or malignant carbuncle, in the ptery- 



588 



DISEASES OF THE NERVOUS SYSTEM. 



goid plexus and cavernous sinus ; if stasis from cardiac feebleness and hy • 
perinosis, in the longitudinal sinus. The thrombus and the subsequent 
changes taking place in it are the same as those already described. 
The vessels entering the sinus, the seat of occlusion, are turgid, tortu- 
ous, and their tunics weakened, so that they yield to the increased pres- 
sure, and haemorrhages occur at various points, on the hemispheres, 
especially in the cortex. Softening occurs to a small extent about the 
hsemorrhagic extravasations, and meningitis may arise as a complication. 

Symptoms. — As the cases of thrombosis of the sinuses occur in the 
subjects of wasting maladies, or of cardiac feebleness, the symptoms 
produced by the thrombus are superadded to those of the original 
malady. The signs by which such an occurrence may be recognized 
are all the more obscure, since the anaemia of the brain may be accom- 
panied by many of them. There have been observed the following : 
rigidity of the cervical muscles, the occiput being buried in the pillow, 
and sometimes general muscular rigidity ; ptosis, strabismus, nystagmus, 
and paresis of facial muscles ; hebetude of mind, stupor passing into 
coma, sometimes delirium ; headache, vertigo, nausea and vomiting ; de- 
lirium, ending in coma ; contractures, or paresis, local tremor, clonic 
convulsions ; paralysis may be crossed with contractures and rigidity. 
Indeed, so various and diffused are the symptoms that the diagnosis 
must always be in the nature of a guess. More importance is to be at- 
tached to circulatory disturbances affecting external vessels. The facial 
vein communicates with the pterygoid plexus of veins and the cavern- 
ous sinus ; the nasal veins communicate through the foramen caecum 
with the longitudinal sinus, and the occipital veins communicate with 
the transverse sinus by the emissaria mastoiclea.'^ Hence, bleeding at 
the nose, puffiness of the eyelids, swelling of the facial vein, and of 
the occipital veins, accompany thrombosis of the sinuses. From the 
same cause there will be prominence of the eyeballs, injection of the 
conjunctivae, and a swollen and tortuous condition of the retinal veins, 
cloudy swelling of the optic disk (choked disks), etc. In the case of 
thrombus of the cavernous sinus, there may be irritation by pressure 
of the fifth nerve, and consequent neuralgia— of the fourth, and inter- 
nal strabismus ; of the oculo-motor, and contracted pupil and external 
strabismus, etc. These symptoms have a high degree of importance if 
present ; but their absence does not negative the existence of throm- 
bosis. During the course of chronic otorrhcea and caries of the petrous 
bone, cerebral symptoms may supervene, and a fever of septicaemic 
character develop. When delirium tending to coma accompanied with 
typhoid symptoms appears during erysipelas or phlegmon of the upper 
lip, there may be suspected, as in the former case, that the new symp- 
toms maybe due to thrombosis of a sinus. The diagnosis must always 
be largely conjectural. 

* Henle, " Gefasslehrc," p. 341. 



CEREBRAL HEMORRHAGE. 



589 



Treatment. — The treatment consists in the free use of carbonate of 
ammonia and quinine, given with the objects in view indicated under the 
head of occlusion of the cerebral vessels. Unfortunately, when this 
accident occurs, there is little chance of accomplishing any good. 
Whenever a phlegmon of the upper lip appears, the probability of this 
accident should be kept in view. Free administration of quinine is un- 
doubtedly serviceable in preventing this complication. 

CEREBRAL H.SIMORRHAGE. 

Definition. — By this term is meant, the giving way of a vessel and 
the escape of blood into the cerebral tissues. Apoplexy is sometimes 
used synonymously with cerebral hemorrhage, but incorrectly, since it 
is a symptom merely, and not a disease. 

Causes. — The principal cause of cerebral hemorrhage is disease of 
the vessels — aneurismal dilatations seated on the arterioles and vary- 
ing in size from a pin's-head to bodies too minute for the unaided sight 
to recognize. It is rare for these bodies to form before forty, but they 
occur with increasing frequency with the advance in life. The change 
is a periarteritis and begins in the perivascular lymph-sheaths, thence 
extends to the adventitia, the muscular layer dilates, and the aneurism 
is formed.* Atheromatous degeneration of the tunics of the vessels 
may be an indirect cause, by leading to the formation of the miliary 
aneurism. Increase in the blood-pressure is said to have an influence 
in causing haemorrhage, but not directly. When disease has weakened 
the vessels, an increase in the blood-pressure will cause them to yield, 
but, without such change in the walls of the vessels, mere variations 
of pressure will not suffice. The principal source of increased blood- 
pressure is hypertrophy of the left ventricle — that form associated 
with hypertrophy of the muscular layer of the arterioles and contract- 
ed or fibroid kidney. Besides the constantly exalted pressure, the 
intra-cranial vessels may be exposed to sudden increased strain by a 
variety of causes : by stimulants, as alcohol, opium, coffee, tea, etc. ; 
by a cold or hot bath, by a full meal, and by moral emotion. Cerebral 
haemorrhage is notably increased by the cold weather of autumn. Ve- 
nous hypersemia may lead to cerebral haemorrhage, as coughing, strain- 
ing at stool, coitus, etc., but disease of the vessel-walls must pre- 
dispose to the accident. The arterial disease on which haemorrhage 
depends is probably transmissible, for it is a matter of common ob- 
servation that the tendency to cerebral haemorrhage is inherited. 

Pathological Anatomy. — Certain parts of the brain seem particu- 
larly liable to cerebral haemorrhage : the corpus striatum, the lenticular 
nucleus, the thalamus opticus. When these parts are affected, the dam- 
age is not always confined to them, but the neighboring parts of the 
* Eichler, *' Deutsch. Archiv f iir klinisclie Med.," xxi, 1, 32. 



590 



DISEASES OF THE NERVOUS SYSTEM! 



hemispliere are damaged simultaneously, and the lobes of tlie hemi- 
spheres are often separately attacked, the anterior and middle more fre- 
quently than the posterior lobe. ISText in point of frequency, but much 
less often, the cerebellum is involved, and lastly, although rarely, the 
pons and medulla. The blood is not necessarily confined to the point 
whence it escaped : it may break through to the surface or into the ven- 
tricles and pass by the iter from the third to the fourth ventricle. When 
the amount is large, the dura mater may be put on the stretch, the con- 
volutions compressed, the sulci lessened in depth. The blood may be 
collected in a mass or focus, or it may be spread out into a more or 
less thin layer. When in a focus, as is most usual, the collection is 
somewhat circular and varies in size from a pea to an English walnut, 
or larger. There may be one or several foci, and they may occur in 
symmetrical parts — as a focus in each corpus striatum, for example. 
Besides a recent there may remain the evidences of former haemor- 
rhages. Immediately after it has occurred there is a blood-clot, dark 
in color and homogeneous in its constituents, which are those of blood 
merely, although around it is broken-down cerebral matter, mixed 
with blood-clot, and in the mass somewhere will be found, if carefully 
traced out in water, the affected vessel and its ruptured miliary aneu- 
rism. Soon after the clot has formed, separation begins, and the fibrin 
collects in the center of the mass or at the periphery, while the cor- 
puscles adhere in a group, and the serum pressed out saturates the adja- 
cent broken-up cerebral matter. The next step, if death does not oc- 
cur, is the retrograde change in the blood-clot, which becomes first of 
a dark chocolate-color, but the hsematin disappears, the watery part 
is absorbed, and a yellow, puriform-looking material only remains. A 
limiting inflammation may occur in the adjacent cerebral matter, a con- 
nective-tissue membrane of a spongy structure forms, and the remains 
of the clot will be inclosed in this. Besides the yellowish, puriform 
fluid or a whitish, whey-like fluid, there are contained crystals of pig- 
ment in the meshes of the cyst-walls. The clot and the surrounding 
brain-substance do not always undergo this favorable disposition. An 
inflammation may be lighted up in the brain-tissue, around the clot, 
in a few days after it has formed, producing extensive softening and 
oedema. The cysts formed may continue indefinitely without further 
change, or they may ultimately disappear, leaving only a cicatrix of 
considerable area, but thin, and composed of either dense connective 
tissue, or of a spongy material containing pigment. The changes due 
to cerebral heemorrhage are not limited to the site of the original in- 
jury. Some months afterward an atrophic degeneration has taken 
place in the nerve-fibers of the pyramidal tracts. These degenerative 
changes do not follow all cases of cerebral haemorrhage. They occur 
after haemorrhage into the internal capsule, the corpus striatum, the 
gray matter of the motor zone, and the subjacent white substance, and 



CEREBRAL E^MORRHAGE. 



591 



less so when the lesion is in the optic thalamus and centrum ovale, 
and not at all when the haemorrhage is in the caudate nucleus.* The 
atrophy extends downward through the crus, the pons, and the py- 
ramidal tracts, and consists in wasting of the nerve-elements and an 
increase of the connective tissue. 

Symptoms. — Many cases of cerebral haemorrhage are preceded by 
distinct prodromes. The most usual are those connected with chronic 
arteritis, which may lead to thrombosis, or less frequently those de- 
pendent on cerebral hypersemia. Headache, vertigo, sudden attacks 
in which the mind is confused, the memory for words is lost, or mis- 
takes in the use of words occur ; changes in the disposition, becoming 
morose, dejected, and irritable, weakness of a limb or of one side, 
numbness, tingling, or a feeling of coldness in a member or several 
members, double vision, weakness of the tongue, paresis of the facial 
muscles, etc. Sometimes, as the author has witnessed, the apoplecti- 
form variety of cerebral congestion is followed in a few weeks by 
severe or fatal cerebral hsemorrhage. In many cases there are no 
"warnings," no prodromata, but the hsemorrhage occurs suddenly. 
The character of the seizure varies greatly. It may be apoplectic ; the 
patient utters a cry or a groan, and falls insensible. Usually some 
symptoms occur just previously to the loss of consciousness ; there is 
headache of a very intense kind, or giddiness with nausea and vomit- 
ing, or the tongue is paralyzed and speech impossible, or there is de- 
lirium or incoherent rambling, or there is gaping, a feeling of great 
desire for sleep, and increasing drowsiness, or there may be intense 
weakness of the limbs and a feeling of exhaustion, or one limb may be 
seized with intense numbness and tingling, or there may be spasm 
of the muscles soon to be paralyzed — in a great variety of ways the 
attack may be announced some hours or minutes before the blow falls. 
The patient passes into unconsciousness, with complete muscular re- 
laxation, and the extinction of reflex movements, the action of the 
heart and the respiration continuing. In the less severe cases the 
unconsciousness is profound, but strong irritation may induce reflex 
movements, and swallowing is possible if the substance is placed in 
the pharynx, and a difference between the movements of the two sides 
is also apparent. The eyes— and the head, also, frequently — deviate 
toward the side affected in the brain and from the side paralyzed : 
this movement constitutes a means of diagnosis between cerebral haem- 
orrhage and other causes of profound unconsciousness. Convulsions 
of the epileptiform variety may occur, when the haemorrhage causes 
unconsciousness, and usually signifies large haemorrhage, or haemor- 
rhage into the pons or medulla. When the haemorrhage occurs slowly, 
and the patient glides gradually into unconsciousness, there may be 



* Flechsig, "Archiv fiir Heilkunde," IS'ZY, and No. 53, 18'78. 



592 



DISEASES OF THE NERVOUS SYSTEM. 



nausea, vomiting, and pallor of the face, but in most cases of cerebral 
hsemorrhage the face is rather red and flushed. There is no constant 
rule as to the size of the pupils : a very minutely contracted pupil 
usually signifies haemorrhage into the pons ; and unequal pupils, one 
being largely dilated, indicate a large haemorrhage breaking through 
into the lateral ventricle. The breathing has usually, but by no means 
invariably, the stertorous character, by which is meant the drawing 
in of the paralyzed cheek with inspiration and its puffing out with a 
sort of explosion in expiration. The pulse is small or full, slow or 
irregular, usually slow and full. There are apoplectic examples of 
cerebral hsemorrhage in which the unconsciousness is not profound — 
the patient may be roused, if he is loudly called, but lapses into a 
soporose state at once. There are many cases in which conscious- 
ness is not lost at all : there may be a temporary confusion, or some of 
the symptoms called prodromal, and then paralysis of one side occurs. 
Often it is sudden and complete ; again it comes on slowly, and is not 
complete for some minutes. In the apoplectic form, death may occur 
during the unconsciousness — in from five minutes to three days. The 
fulminant cases, which terminate in a few minutes, are comparatively 
rare — sudden death being usually caused by heart-disease. If uncon- 
sciousness continues longer than twenty-four hours, death is the usual 
result. The temperature during the period of unconsciousness is low 
— below the normal, one or two degrees — ^but at the end of the first 
day a rise to normal or a little above takes place, and, if a fatal result, 
there is a great rise just before death. Pneumonia is apt to be the 
cause of death, especially when the cerebral lesion is somewhere in the 
right hemisphere, as Brown-Sequard has demonstrated. Consciousness 
may return in a few minutes, but usually in from half an hour to three 
hours. Again, the effects of the seizure may continue for days, there 
being stupor, confusion of mind, defects of speech. The return of 
consciousness is indicated by the revival of reflex excitability, by the 
effects of irritation, etc. The progress of restoration may be retarded 
by the onset of inflammatory symptoms at the expiration of two or 
three days ; the temperature rises a degree or two ; headache, confu- 
sion of mind, and delirium occur ; tonic contractions (" early rigid- 
ity") ensue in the paralyzed muscles, and they become the seat of 
severe pain, which may persist for a month or more, while the other 
symptoms disappear in a few days. 

When the disturbances due to the seizure subside, then may be 
clearly seen the extent of the paralysis. The shock of the attack sus- 
pends the functions of many parts of the cerebrum, which soon func- 
tionate again as these effects of the injury subside. Various paretic 
and paralytic symptoms, that appear at first, quickly cease, but the 
more permanent results are the more evident. The amount of paraly- 
sis varies from a hardly appreciable weakness to an absolute extinction 



CEREBRAL HEMORRHAGE. 



593 



of motility. As there is usually but one focus of haemorrliage, the 
resulting paralysis is unilateral^ and on the side opposite the lesion, 
and involves the muscles of the face, of the tongue, of the body, and 
of the extremities — right or left hemiplegia — according to the cere- 
bral hemisphere invaded. The muscles of the face paralyzed are those 
of expression, and are innervated by the seventh nerve. Those branches 
of the nerve distributed to the orbicularis palpebrarum, corrugator 
supercilii, and the frontalis are but slightly alfected, the labio-nasal 
fold is flattened or obliterated, and the corner of the mouth is de- 
pressed. The tongue when protruded deviates toward the paralyzed 
side, and the palate may hang lower than normal and turned toward 
either side. In consequence of the paralysis of the expression muscles, 
many movements become awkward or impossible, as whistling, purs- 
ing up the mouth, laughing, etc. The muscles of the chest are paretic, 
and respiration somewhat hindered thereby (Nothnagel). The ex- 
tensors seem to be more affected than the flexors, but this is only 
apparent, because of the greater power of the latter. Notwithstanding 
the immense preponderance of cases proving the crossing of the motor 
fibers, and consequently the occurrence of hemiplegia on the side 
opposite the seat of the lesions of the brain, there are opposing obser- 
vations. Bilateral paralysis may be due to simultaneous lesions on 
both sides, and in this way bilateral hemiplegia may be produced. 
Paralyses are said to be " alternating " or " crossed " when the paraly- 
sis of the face is on one side and of the extremities on the other. This 
may occur in lesions of the pons, etc. Although the paralyzed parts 
may be motionless, they may execute " associated movements " : thus, 
in coughing or sneezing the paralyzed member may give a jerk, or may 
imitate movements performed by the healthy side. The contractions 
which accompany the haemorrhage, or which are excited by an inflam- 
matory process about the site of the clot in a few days after the seizure 
(early rigidity), have already been referred to. The contraction which 
occurs later, after the paralysis has existed for a long time, is known 
as " late rigidity," but its intensity and persistence bear no constant 
relation to the character of the case, except its duration, and rigidity 
may not be present at all, although not often absent. Bouchard's ex- 
planation that the rigidity depends on the atrophic descending changes 
in the pyramidal tract continues to be the most generally accepted 
theory of this phenomenon, but it is not altogether satisfactory. 
Besides rigidity, long-paralyzed members may be affected by choreic 
movements, first described by Wier Mitchell and subsequently studied 
by Charcot, under the title " post-hemiplegic chorea," and now 
ascertained to be produced by changes in the motor centers on the 
opposite side. We have further to note that the paralyzed muscles 
preserve their electric excitability. Under some circumstances the 
40 



594 



DISEASES OF THE NERVOUS SYSTEM. 



electric excitability may be heightened, under others lessened, but this 
lowering of electro-contractility becomes more decided the more nearly 
the paralysis approaches the " spinal " character, which is the case in 
lesions of the cerebral peduncles, of the pons, and of the medulla. 
Immediately on the receipt of the injury done by the haemorrhage, the 
sensibility is paralyzed with the motion, but the sensibility is soon 
restored, as a rule, although sometimes the restoration is very gradual, 
and it is rare for it to be complete. Anaesthesia and analgesia do not 
accompany lesions of the corpus striatum, whence it happens that these 
functions are so seldom permanently impaired in hemiplegia. In 
some cases — lesions of the thalamus, corona radiata, etc. — anaesthesia 
may be a constant symptom. Anaesthesia may be followed by hyper- 
algesia, and the paralyzed members may be the seat of neuralgia. 
Various trophic changes occur in hemiplegia. With the first hemi- 
plegia, the paralyzed parts are usually somewhat swollen, are red, and 
possess a slightly higher temperature, and sweat a good deal. These 
symptoms subside in a few weeks or two or three months ; the alfect- 
ed parts become cold, pale or bluish, the skin scaly and dry, and the 
nails grow wrinkled, thickened, brittle, and incurved, and the hair 
changes in texture and length. The skin grows thicker and tougher 
in many cases, and the larger joints may be the seat of an acute syno- 
vitis. In addition to these trophic affections should be mentioned 
the fact that the paralyzed members in hemiplegia rapidly ulcerate 
by pressure (bed-sores). 

Course, Duration, and Termination — In the fulminant form death 
may occur in a few minutes, never less than fifteen. There may be 
a partial revival, the consciousness restored more or less completely, 
and then a new attack occurs, closing the scene usually in a day or two. 
The apoplectic symptoms having disappeared, the next danger consists 
in the inflammation about the clot, the febrile excitement, headache, and 
delirium, which usually prove fatal within a week, unless very mild and 
transitory. Having passed this period there is a partial recovery with 
hemiplegia, which may gradually disappear, leaving but slight traces 
of the original mischief. There are but few if any who are restored 
entirely in all their mental powers, although the motor paralysis may 
have ceased. If changed in no other way, they are emotional, easily 
excited to tears, or become altered in disposition, appearing irritable, 
excitable, peevish. Usually memory is impaired, especially for the 
events of the time, while matters long past of early life may be vividly 
recalled. The memory for words may be impaired slightly, may be 
very defective, or may be entirely lost, constituting the condition of 
aphasia. This may include inability to express ideas by signs. There 
may be a gradual decline in the mental powers, the patient lapsing 
into dementia. The duration of a case of hemiplegia is very uncertain 
— many continue for ten, fifteen, even twenty years. But hemiplegics 



CEREBRAL HEMORRHAGE. 



695 



are always threatened by a new attack, since the lesions which origi- 
nally caused it are yet present. Another attack or two is the usual 
course, proving fatal ultimately unless cut off by an intercurrent dis- 
ease. 

Diagnosis. — As the subject of the distinction between occlusion of 
the cerebral vessels and cerebral haemorrhage has been discussed, it 
remains now to indicate the seat of the lesions by the symptoms. The 
diagnosis of the position of the haemorrhage by the symptoms rests on 
the knowledge of cerebral localizations. Lesions of the cortex and of 
the medullary substance of the hemispheres give rise to paralysis 
on the opposite side of the body. If slight in extent, recovery may 
ensue. A lesion confined to the third left frontal convolution has pro- 
duced aphasia only. Disturbances in the mental functions are usual 
and are more decided than the psychical symptoms produced by cere- 
bral haemorrhage into other parts. Haemorrhage into the anterior lobe 
causes paralysis of the opposite half of the body, and aphasia if the 
left is the seat of the lesion. Haemorrhage into any of the parts sup- 
plied by the left middle cerebral artery will produce disturbance in all 
the modes of expressing ideas bywords and signs. Sensibility as well 
as motility is disordered in haemorrhage into the posterior middle lobe 
and into the posterior lobe. Disturbances of vision and optic neuritis 
accompany the paralysis, and psychical disorders, with a special ten- 
dency to emotional manifestions, are pronounced features. Haemor- 
rhage breaking into the ventricles is accompanied by formidable symp- 
toms ; by deep coma, sometimes by convulsions, partial or general, 
occasionally by contractions of the paralyzed parts, by unequal pupils, 
one being widely dilated. Haemorrhage into the corpus striatum, 
the most usual site of cerebral haemorrhage, is followed by paralysis 
of the members, body, and face on the opposite side ; and, if in the 
left corpus striatum, affections of speech, sometimes complete apha- 
sia, are usually present. There are no disturbances of sensibility in 
these cases of hemiplegia from haemorrhage into the corpus striatum. 
As the optic thalami have never been invaded by haemorrhage strictly 
limited to them, the results of lesions are hemiplegia of the opposite 
side and affections of sensibility. It is probable that the motor symp- 
toms are due to simultaneous injury to the corpus striatum. Hemor- 
rhage into the pons or medulla is very fatal— in from fifteen minutes 
to several hours. There are convulsions usually, general muscular res- 
olution, and minutely contracted pupils. If the immediate results are 
passed over, various motor disturbances ensue : there may be paralysis 
of both sides, or paraplegia, paralysis of one side, or hemiplegia ; pa- 
ralysis of the members on one side and of the face on the opposite 
side, or crossed paralysis ; also sensory disturbances : there may be 
anaesthesia with the paralysis of one side, and the paralysis of sensa- 
tion may be " crossed," as is the motor paralysis. 



596 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — If the prodromal symptoms threaten an attack of 
cerebral haemorrhage, venesection, as the most prompt and efficient 
means for reducing the intra-cranial blood-pressure, should be at once 
practiced, the amount drawn being decided by the effect produced. 
In feeble subjects, leeches to the mastoid may be substituted for vene- 
section. An active purgative (compound extract of colocynth gr. vj, 
croton-oil gt. j) should be administered. Counter-irritants should be 
applied to the extremities, and an ice-bag to the scalp. If the haem- 
orrhage have occurred, these measures will be useless. The utmost 
quiet should then be maintained, the head elevated, the room dark- 
ened. Excellent results are then obtained by the use of tincture of 
aconite-root, beginning immediately after the coma has passed off. 
One drop every two hours will usually suffice, as it is not necessary 
to reduce the pulse by it, unless the reactive fever is considerable, 
when the dose mentioned may be given every hour for a day or two. 
When the reaction period has passed, or at the end of two weeks, 
much may be accomplished by the judicious use of ammonia (aramon. 
carb. gr. v, liq. ammonii acetat. 3 ss., four times a day), continuing it 
for a month or more, or until the retrograde changes in the blood- 
clot are accomplished. Then the time has arrived for the application 
of galvanism, a weak current — say from four cups — being passed 
through the brain in both directions, or from behind forward, and 
from both mastoids. The application should be daily, and for three 
minutes at a seance. To assist in the restoration, the lactophosphate 
of lime (sirup) should be administered three times a day with the 
meals, and the diet should be nourishing and yet unstimulating. As 
the tendency of paralyzed parts is to waste, the members should from 
the beginning be subjected to daily massage, at first very lightly, and, 
if wasting of the muscles is considerable, they should be exercised by 
faradization. If there is much contraction of the flexors, the extensors 
should be faradized, and the flexors should receive a continuous mild 
current to allay their irritability. When there is no longer any local 
irritation about the site of the haemorrhage, the injections of strychnine 
should be practiced into the affected muscles. During the long period 
after the absorption of the clot, when the paralysis remains stationary 
or slowly improves, good results are obtained from the persistent use 
of lactophosphate of lime and cod-liver oil, which act as nutrients to 
the cerebral matter. These may be given when electricity and the 
injections of strychnine are practiced. 



CEREBRAL HEMORRHAGE— MENINGEAL. 

Pathogeny. — Haemorrhage into the meninges may be caused by 
injury ; as, for example, the meningeal artery may be ruptured by a 
fracture, involving the anterior inferior angle of the parietal bone. 



PACHYMENINGITIS. 



697 



The most usual cause, probably, is aneurism, and the vessel most 
frequently the seat of this disease the basilar, except the meningeal 
haemorrhage of newly-born children, which is really traumatic, and 
produced by forceps delivery. Meningeal haemorrhage is a complica- 
tion of the acute infectious diseases. The blood is found in a thin 
layer, under the dura or in the cavity of the arachnoid, at the base on 
the hemispheres, and in both situations at the same time. The brain 
itself may be injured by the escape of blood from an aneurism, and 
the convolutions may be depressed, the brain-substance pale and ex- 
sanguine. 

Symptoms. — As meningeal haemorrhage occurs in the adult, the 
phenomena attendant on it are the same as those of a large cerebral 
haemorrhage. There are coma, complete muscular resolution, often 
succeeding to convulsions of an epileptiform character, pupils unequal, 
and reflex movements entirely suspended. Death may occur in a few 
minutes, or after several hours, in profound coma. In other cases 
there are headache, dizziness, nausea, and vomiting, drowsiness, pass- 
ing into stupor, then coma until death after some hours — symptoms 
supposed to be due to the gradual escape of blood from a ruptured 
vessel. In new-born children meningeal haemorrhage is a common 
cause of asphyxia, from which they can not be roused. 

INFLAMMATION OF THE DURA MATER— PACHYMENINGITIS 
EXTERNA AND INTERNA— HiEMATOMA OF THE DURA 
MATER. 

Definition. — By pachymeningitis is meant an inflammation of the 
dura mater. As this membrane consists of two layers, there are two 
forms of the inflammation attacking it : pachyyneningitis, externa and 
interna. Pachymeningitis externa is a surgical malady — an inflamma- 
tion of the external lamella of tlie dura, excited by fractures, penetrat- 
ing wounds, and other injuries of the skull, and by caries of the pe- 
trous portion, involving the dura by contiguity of tissue. The last- 
mentioned malady is so intimately associated with abscess of the brain 
that it is more appropriately studied in connection with that disease. 

Causes. — Pachymeningitis interna — hcematoma of the dura. — Age 
is an important factor, the tendency to this disease increasing from 
twenty upward, the largest number per centum occurring from sev- 
enty to eighty (Huguenin). Three fourths of the cases happen in men, 
doubtless because they are more exposed to the influences producing 
this disease. Trauma plays an important part, with or without frac- 
ture of the skull. In one of the author's cases the haematoma fol- 
lowed a blow on the head — a contusion — with the handle of a heavy 
riding- whip. No doubt the blow which causes the mischief often is 
forgotten, and some other cause assigned. A predisposition may be 



598 DISEASES OF THE NERVOUS SYSTEM. 



created by several morbid states : by chronic alcoholism, scurvy, per- 
nicious anaemia, Bright's disease, sclerosis of the liver, diseases of the 
heart, and obstructive maladies of the lungs. Atrophy of the brain, 
caused by various intra-cranial lesions, seems to be a very important 
factor in the development of hsematoma (Huguenin), and to this may 
be added, by way of illustration, the atrophy of advanced age and of 
chronic alcoholismus.^ 

Pathological Anatomy. — The most commonly accepted view is that 
of Virchow. The first step in the morbid process consists in a hyper- 
gemia of the membrane, and an exudation, developing into a membran- 
ous new formation, proceeds from the sub-epithelial layer of the dura.f 
This neo-membrane contains a multitude of vessels of considerable 
size, and having very thin walls. Haemorrhages, often of considerable 
quantity, take place by the rupture of these vessels, and the size and 
thickness of the neo-membrane are correspondingly increased. Ulti- 
mately the new formation assumes the appearance of a cyst, having a 
smooth surface exteriorly, and containing within a cavity lined with 
blood-clot, shaggy masses of fibrin, partly decolorized, hanging from 
the walls, and a fluid reddish in color and thick with particles of broken- 
up clot. At a later period there may be no appearances of blood-clot, 
except, it is probable, some blood-crystals — there may be only a cyst, 
filled more or less full with a pellucid serum, or instead of a cyst 
with a single cavity there is a mass of connective tissue, its fibers loosely 
united, spongy, with serum more or less fully distending the inter- 
spaces. Before its nature was understood the cyst containing clear 
serum was called " cyst of the arachnoid." It should be understood 
that, between a sac filled with blood-clot and one containing serum 
only, there are various intermediate grades, the blood being more or 
less advanced in the process of disintegration, by which all the mor- 
photic elements are dissolved and decolorized. Huguenin J holds that 
the formation of a hsematoma is not initiated by an inflammation of 
the inner lamella of the dura, but that the process consists merely in 
the organization of a hsemorrhagic extravasation. An immediate vas- 
cular communication is established between the dura and the new mem- 
brane. The usual position of the new formation is on the upper sur- 
face of the hemispheres, extending downward toward the occipital lobe, 
corresponding to the parietal bone, and in more than half the cases on 
both sides. The changes in the adjacent portion of the brain are de- 
pendent on the size and thickness of the neo-membrane. In a case 
observed by the author the cyst was a half -inch in thickness at its 
thickest part, and it depressed the hemisphere correspondingly, the 
convolutions being flattened, the sulci almost obliterated, and the ven- 

* Dr. Jacob Kreminansky, " Ueber die Pacliymeningitis interna baemorrhagica bei 
Menschen und Hundcn," Virchow's " Arcliiv," Band xlii, S. 129-321. 

f Rindfleisch, op dt , p. 620. t Ziemssen's " Cyclopedia," vol. xii. 



PACHYMENINGITIS. 



599 



tricle lessened one half of its area. Atrophy of the brain, atheroma- 
tous deofeneration of the vessels, and the alterations in the structure 
of the brain, accompanying dementia paralytica, are often present. 
Obstructive diseases of the lungs and valvular affections of the heart 
are frequently associated with and apparently have a causative rela- 
tion to this malady. 

Symptoms. — There is necessarily much obscurity about this disease, 
and the symptoms are diffused, and but little characteristic. There 
occur first the indications of excitement of function, followed by those 
of depression. In the first group are an obstinate headache, vertigo, 
singing in the ears, contraction of the pupils to a marked extent, un- 
certainty and feebleness in the movements, without paralysis, wakeful- 
ness, and when sleep comes it is disturbed by exciting dreams. In 
some cases, but less frequently, there occurs an attack, apoplectic in 
character and with the usual phenomena of that state. The period of 
excitation continues from a few days to three months, and is succeeded 
by the signs of cerebral depression. At this point in these cases there 
will usually occur attacks like those of cerebral haemorrhage and from 
the same cause, but in this stage of this disease they are apt to pass 
slowly into unconsciousness. Death may occur in this coma, or the 
patient emerges from it slowly, when there will appear the symptoms 
due to the hsematoma now produced. It should be remembered that 
this new formation is on the surface of the hemisphere, that there has 
been no destruction of the cerebral tissue as in cerebral haemorrhage, 
and that compression is exerted by it on the brain-mass on one or both 
hemispheres. The symptoms now present are persistent headache, 
contracted pupils, and paroxysmal attacks of somnolence, persisting for 
days at a time. If the pressure is on one side only, the corresponding 
pupil is smaller. Paresis of the muscles, contractions, twitching of the 
muscles, are observed on one side when the lesion is unilateral, or they 
may be double. Convulsive movements, limited to a hand, or arm, or 
leg, may be observed. Hemiplegia may slowly develop out of a uni- 
lateral paralysis. After existing on one side for a time, these motor 
disturbances may slowly affect the other side, doubtless because of an 
extension of the disease. In one third of the cases there are defects or 
embarrassment of speech, but rarely complete aphasia. There are not 
any disorders of sensation. The pulse is usually weak, rapid, and 
rather irregular. Fever has been noted in many cases. The pulse may 
be slow during the haemorrhage. 

Course, Duration, and Termination.— The first stage, or that of ex- 
citation, usually lasts but a day or two, yet in exceptional cases it may 
continue a month or two. Death may occur in the apoplexy. The 
period of depression lasts usually from a week to one month, and may 
continue a year, but the most common duration is about twenty days. 
Although death is the usual result, recovery may take place, but it is 
doubtful whether the mental faculties are ever again entirely restored. 



600 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — The remedial management of this disease is a discour- 
aging undertaking. The usual remedies for cerebral hypergemia may 
be used for the symptoms of excitation. 



ACUTE HYDROCEPHALUS— INFLAMMATION OF THE PIA 
MATER : LEPTOMENINGITIS. 

Definition. — The term hydrocephalus signifies water in the brain, 
but is restricted to a disease characterized by the presence of a serous 
fluid in the arachnoid spaces, in the pia mater, in the brain-substance 
(oedema), and in the ventricles. Hydrocephalus may be congenital or 
acquired. In this form — the inflammatory — the presence of water is 
due to an acute inflammation of the^za niater, but without tubercle — 
leptomeningitis. Hydrocephalus is a general term which serves to unite 
various conditions, but it is always a symptom. 

Causes. — Mechanical causes, which prevent the return of blood from 
the vena Galeni and the right sinus, will induce effusion into the ven- 
tricle. Intra-cranial tumors, bands of false membrane, obstruction of 
a sinus or tumors of the neck so situated as to compress the jugular 
vein, belong to this category. Disease of the right heart, obstructive 
diseases of the lungs, as emphysema, sclerosis, etc., may cause hydro- 
cephalus by mechanical interference with the circulation. In advanced 
age, ventricular dropsy occurs in consequence of atrophy and shrink- 
ing of the brain. Various cachexise affect the intra-cranial circulation 
and cause dropsy, as Bright's disease, cancer, tuberculosis, etc., but 
only the first-named stands in a causative relation to the form of hy- 
drocephalus here considered. Dropsy of the ventricles coincides with 
general dropsy from cardiac and renal diseases. Leptomeningitis is a 
disease of early life, from one to five years of age, but it may occur at 
any age. Unfavorable hygienic conditions increase the tendency to 
it, and the predominance of the nervous system in the bodily confor- 
mation invites this, as other forms of nervous disease. Both sexes 
are affected alike. Among the exciting causes may be mentioned 
dentition, the eruptive fevers, and blows on the head. 

Pathological Anatomy. — The effusion is usually confined to the 
ventricles, but there may be considerable distention of the subarach- 
noid spaces, cedema of the pia and of the neighboring portions of the 
brain. When the effusion is limited to the ventricles, the brain-tissue 
is found to be moister from the gray matter inward. More or less 
softening by imbibition exists for a short distance from the ventricles. 
The choroid plexus is hyperjemic, and may contain minute extravasa- 
tions. The ventricles are usually symmetrically dilated, but, in the 
hydrocephalus of the aged, one ventricle may be very much dilated 
and the other encroached on and narrowed. 



ACUTE HYDROCEPHALUS. 



601 



Symptoms. — There are several modes of onset, and several types of 
cases, as the causes sufficiently indicate. One variety, known as " serous 
apoplexy " by the older writers, begins, by reason of a sudden effusion, 
very abruptly, with the phenomena of apoplexy : there are unconscious- 
ness, muscular resolution, immobile pupils, involuntary evacuations. 
In the midst of the coma there may sometimes arise delirium. So ex- 
treme may be the pressure of the fluid that the medulla oblongata 
ceases to functionate, and the patient dies in a few hours, and rarely 
is life prolonged several days. The next type may be characterized 
as the convulsive. This begins with the symptoms of excitation, and 
there may be some f everishness, headache, nausea, and vomiting, for a 
few days, w^hen an attack of eclampsia occurs, or the convulsion may 
be the initial symptom, or in adults a violent delirium. These symp- 
toms are soon followed by depression, and the patient passes into a 
stupid, somnolent state, is roused w^ith difficulty, and weakness of the 
members is succeeded by complete paralysis. Very unexpectedly, some- 
times, the consciousness revives, but for a brief period, and the coma 
comes on again, death soon occurring. This form usually appears in 
the course of Bright's disease or general dropsy. The ordinary form 
in children sets in with feverishness, headache, intolerance of light, and 
corrugation of the forehead ; intolerance of sounds, restlessness, deliri- 
um toward evening, wakefulness, or disturbed sleep ; vertigo, twitch- 
ing and spasmodic contraction of muscles (head drawn back, fingers and 
toes incurved) ; great sensitiveness of the skin, pain being caused by 
a slight touch, especially about the neck ; nausea and vomiting without 
cause, the belly drawn in, and obstinate constipation. Such symptoms 
will continue for several days, when there will occur convulsions of an 
epileptiform character, or partial convulsive movements in an extremity, 
in the muscles of the abdomen, or in the face. The temperature may 
rise very high during these convulsive attacks— the pulse rapid, and 
often irregular — but the temperature declines after the eclampsia has 
ended. Death may take place at this period, or, as is most usual, the 
epileptiform attacks cease and the ordinary course of the disease is 
resumed. The symptoms of depression now come on : restlessness is 
replaced by stupor, rigidity and contraction of the muscles by paresis, 
heightened sensibility by anaesthesia. The pupils dilate somewhat 
and become less and less niobile, and are often unequal in size, and 
double vision is noticed. The pulse declines in force, and exhibits a 
marked degree of inequality, now beating at 80, now at 130. The res- 
pirations become irregular in rhythm, and manifest the Cheyne-Stokes 
type to some extent. The surface becomes cool ; the fontanelles are 
prominent and rounded ; and the sutures in young infants separate 
somewhat. The vomiting continues, and the nutrition is greatly im- 
paired. The patient sinks into a deep coma, and, although there oc- 
cur remissions, in which the unconsciousness seems less profound, the 



602 



DISEASES OF THE NERVOUS SYSTEM. 



pulse and breathing better, and the reflex movements more easily ex- 
cited, they do not persist. 

Course, Duration, and Termination. — A few cases have been re- 
ported cured. They were milder examples of the common type, as 
seen in children, and, although the symptoms of excitation were well 
marked, those of depression did not come on. The apj)earances of 
improvement, which are observed in the stage of depression, are illu- 
sory. The apoplectic and convulsive forms are always fatal in a few 
hours or two or three days ; the common form very rarely terminates 
in recovery. The duration of the cases terminating by exhaustion is 
very protracted, reaching to four, six, even eight weeks, but the aver- 
age duration of these cases is about three weeks. Those ending by 
convulsions do not often continue beyond two weeks. The extended 
duration of some cases is due to the absence of convulsions and the 
prolongation of the stage of coma. As the questions connected with 
diagnosis and treatment are the same as for tubercular meningitis and 
for simple meningitis, they are postponed for separate and full con- 
sideration at the conclusion of the subject of meningitis. 

CHRONIC HYDROCEPHALUS. 

Pathogeny and Symptoms. — Chronic hydrocephalus, as it occurs 
in children, usually succeeds to the acute form, and is a result of 
rickets, or an accident of the rachitic constitution. The quantity of 
fluid is much greater, however, in the acute form. After youth, the 
accumulation of fluid is due to the pressure of tumors on the straight 
sinus, vein of Galen, etc., and in old age considerable effusion is pro- 
duced by atrophy of the brain. In dementia paralytica, there may 
be considerable distention of the ventricles and of the perivascular 
lymph-spaces. The initial symptoms are those of irritation, and are 
due to the presence of the new vascular conditions, but, as the effusion 
grows, the neighboring parts are pressed upon, and the symptoms of 
depression then dominate the situation. Hebetude of mind, stupidity, 
diminished activity of the special senses, and a fatuous expression 
of countenance, are now observed. General sensibility — tactile, heat, 
cold, and sensory — is much less active than normal. Motility is also 
impaired, especially in the distribution of the seventh nerve : there 
are present ptosis and a blank expression due to relaxation of the 
muscles of expression. The pupils are unequal, and respond slug- 
gishly to the action of light. The tongue is paretic, and the speech 
thick and utterly unintelligible. The faculties continuously decline 
into idiocy or dementia ; locomotion becomes impossible ; control of 
the sphincters is lost ; sight and hearing are abolished. This slow 
decline may be diversified by convulsive seizures, or more acute 
symptoms may be produced by a sudden and large effusion. In the 



CONGENITAL HYDROCEPHALUS. 



603 



latter, unconsciousness may occur, preceded by violent headache, and 
followed by inequality of pupils, hemiplegia more or less complete, 
slow, irregular pulse, impaired articulation, aphasia, etc. The dura- 
tion of the cases is measured by months, and the termination is fatal. 
The fatal result may be caused by the ordinary progress of the dis- 
ease — the compression of the increasing effusion, or by some intercur- 
rent disease, as pneumonia, pleuritis, meningitis, etc. The treatment 
is the same as for the congenital form, to which the reader is referred. 

CONGENITAL HYDROCEPHALUS. 

Causes. — Much obscurity obtains on this point. Imperfect formation 
of the cranium and defective development of the brain are influential 
causes. A chronic inflammation of the ependyma seems to develop 
the disease sometimes. Again, it is the product of purely mechanical 
agencies, such as the compression, by a tumor, of the straight sinus or 
of the vena Galeni. 

Pathological Anatomy. — There is no constant ratio between the size 
of the head and the amount of liquid present. The fluid may vary 
from an ounce or two to sixteen ounces or more. The liquid is trans- 
parent, of a straw-color, and contains but little solid matter, which 
consists of albumen and chloride of sodium. If the fluid is consider- 
able, the ventricles are much distended, the optic thalami and the corr 
pora striata are depressed and flattened, the orifice between the two 
ventricles is very large, and the roof of the ventricles is thinned ac- 
cording to the amount of fluid, and may be to the extent that only a 
mere line of white and gray matter remains. From this extreme dis- 
tention to the mere filling of the ventricles without disturbing the 
harmony and proportion of parts, there are numerous variations in the 
quantity of fluid. The enlargement of the head caused by the effusion ' 
may be sufficient before birth to impede or prevent natural delivery. 
The degree of ossification is an important element in the dimensions. 
The bones are so thinned as to be translucent ; the fontanelles and the 
spaces between the sutures are very wide ; the lateral portions of the 
cranium project greatly ; the forehead bulges out enormously over the 
eyes ; the orbital plates are depressed, whence the eyes are forced for- 
ward between the lids, producing the condition of exophthalmus. 

Symptoms.— The dimensions of the head at first attract attention to 
the condition of the infant. At the period when the head should be 
held erect it is found to droop, resting on one or the other shoulder. 
Then it is noticed that the mental development does not grow with the 
physical ; that the face is devoid of expression ; that the attention is 
not attracted by surrounding objects ; that voluntary movements are 
slow of execution. When the period for standing on the feet and, 
making attempts at walking arrives, the power to maintam the erect 



604: 



DISEASES OF THE NERVOUS SYSTEM. 



posture is wanting. The general condition is not favorable, and, al- 
though the appetite may be voracious, the assimilation is not equal to 
the preparation of the aliment for absorption. The face has a rather old 
look, and is wrinkled ; the voice is feeble and sibilant. Some of these 
subjects are, however, capable of slight mental development, but they 
do not acquire any higher capacity for speech than the automatic use 
of a few words, and, if they reach manhood, the mental powers are only 
those of a child, the voice having the same characteristics. As regards 
the special senses, odor and taste are more often preserved, while hear- 
ing is imperfect. Disorders of vision and of the cutaneous sensibility 
are common. N^umbness, tingling, and pains are felt in the extremi- 
ties. Motility is impaired to a less or greater extent. There may be 
a general paresis, which is more pronounced in one member, but rarely 
complete paralysis. There are great diiferences in the cases : some 
can not stand without support ; others walk, but the gait is hesitating ; 
they stumble at every obstacle, and seem constantly to be about to pitch 
forward, owing to the weight of the head. Epileptiform attacks occur 
in many of the cases from time to time. The nutrition is bad, not- 
withstanding a voracious appetite ; they suffer from constipation, and 
have an excessive flow of saliva from the mouth ; the skin is dry and 
the eyelids are puffy. If the anterior fontanelle is very large, strong 
compression will put the patient into a somnolent, even a comatose state. 

Course, Duration, and Termination. — The course of the disease is 
chronic, its march irregular. At times considerable progress is made ; 
then the case remains stationary for some time, even for years. A 
majority of the cases terminate within the first year ; others are pro- 
longed to the fifteenth year, even beyond this. The more voluminous 
the head, the more rapid the progress of the case, as a rule. Sponta- 
neous cures have been effected by the discharge of the liquid, either 
by a wound or through the nose. Cures may be effected in slight 
cases when recognized early, but such a result is exceptional, the usual 
termination being death. The fatal result is reached by convulsions 
and coma, unless previously by some intercurrent diseases. 

Treatment. — The author has had good results from the use of iodide 
of potassium, but it was a case of effusion probably, limited to the ven- 
tricles. Flying-blisters, the internal administration of digitalis, ergot, 
and purgatives, with the occasional use of iodide of potassium, carried 
to slight iodism, are the remedies best adapted to the cases of slight 
extent, which may be conducted to a favorable termination. The use 
of the finest aspirator-needle may now be justified, in view of the spon- 
taneous cures which have followed accidental discharge of the fluid. 
Care being taken to avoid the longitudinal sinus, the ventricle may be 
entered with safety, and the operation is easily performed. When suf- 
ficient fluid is withdrawn, the cranium should be gently but firmly com- 
pressed. 



TUBERCULAK MENINGITIS. 



605 



TUBERCULAR MENINGITIS. 

Definition. — By this term is meant an inflammation of the cerebial 
meninges, caused by the presence of tubercular granulations. 

Causes. — Tubercular meningitis occurs most frequently in children 
from two to six years of age, and in adults from twenty to thirty years, 
and is about equally distributed between the sexes. Children of the 
well-to-do classes are apt to suffer from this disease, and those whose 
nervous system preponderates over the digestive and muscular. The 
" gelatinous children of albuminous parents," as the phrase goes, pos- 
sess a special susceptibility to tubercular meningitis — the pale, thin- 
skinned, blue-eyed, precocious children of pale, flabby, and delicate 
parents. The changeable weather of winter and spring disposes to the 
development of the disease. All the circumstances comprehended in 
the term had hygiene promote the occurrence of this malady, especially 
insufiicient light, bad air, and improper food. None of these causes 
could produce this disease in the absence of the tubercular matter. It 
is extremely rare to find the tubercular deposits limited to the pia 
mater — in thirty-eight examples of the disease there were but two in 
which the deposit was thus limited (.Jaccoud). Tubercular meningitis 
!§ transmitted by inheritance in the limited sense that the diathesis is 
inherited : in one member of a family so tainted it may be meningitis, 
in another phthisis, in a third ulceration of the intestine. 

Pathological Anatomy. — Miliary tubercles, in the form of grayish- 
white granules having a translucent and somewhat gelatinous appear- 
ance, are distributed along the vessels of the pia mater. These miliary 
granules vary in size from a minute object just visible to the eye up to 
a large pin's-head, and these aggregating in a mass form a tubercle as 
big as a pea. The distribution of the tubercle-granules is not the 
same in all situations : it may be greater in the neighborhood of the 
arteries of the base (basal meningitis) or the arteries of the convexity ; 
again, the principal deposits may be in the pia of the frontal or of the 
parietal regions. There may be but few tubercles in any situation in 
some cases ; in others the w^hole membrane may be thickly studded 
with them. The intensity of the inflammation does not have a con- 
stant relation to the number of tubercles, for the inflammation may be 
great with few tubercles, and slight with a large crop of tubercles. 
Besides tubercle there are present the evidences of suppuration in a 
sero-purulent effusion, seen along the course of the vessels especially, 
as "yellowish stripes" (Kindfleisch). The pia mater at the base is 
thickly covered with a gelatinous exudation, and the membrane itself 
is thickened and opaque, especially about the optic chiasm and the an- 
terior perforated space extending up into the fissure of Sylvius. There 
is more or less effusion usually in the ventricles, and the plexus cho- 
roides is the seat of an extreme hypen-emia. More or less oidema of the 



606 



DISEASES OF THE NERVOUS SYSTEM. 



cortex takes place, provided there is no effusion, but when there is effu- 
sion the cerebral substance is dry and anaemic from pressure. Miliary 
tubercles are also found in the cortex, and migrated white corpus- 
cles are abundantly distributed through the cerebral tissues. The mil- 
iary tubercles, aggregated in masses, are found in many situations to 
have undergone caseous or fatty transformation. Tubercles are also 
widely distributed throughout the body. 

Symptoms. — There is a period during which it is probable tuber- 
cular deposit is taking place, manifested by symptoms which may be 
justly called prodromal. The disturbances resulting in the symptoms 
of the disease are produced by the inflammation which is excited by 
the tubercular deposit. The prodromal symptoms are chiefly those in- 
dicative of failure of nutrition ; emaciation goes on, and the strength 
declines proportionally ; the appetite fails, and the character changes, 
the patient becoming irritable and morose. The child, before preco- 
cious and vivacious, becomes indifferent to former occupations and 
amusements. Sleep is disturbed by vivid dreams ; the child grinds its 
teeth, cries out suddenly in the night, and walks about in a somnam- 
bulistic state. The digestive organs become disordered, the belly is 
swollen, diarrhoea alternates with constipation, and vomiting occurs 
without cause, without the presence of indigestible matters to excite it. 
Headache is complained of, vertigo is experienced in rising ujd to walk 
or in lying down, and pains are felt in the limbs. The ominous symp- 
tom of double vision is sometimes observed at this period. The author 
has heard a precocious little boy say during this prodromal period, " I 
see two mammas," several weeks before the developed disease came 
on. The stage of excitation symptoms Jippears in from two days to six 
weeks, even longer, of the prodromal period. Fever begins ; the tem- 
perature rises to 102° or 103° Fahr. in the evening, and falls in the 
morning to 99° ; the pulse varies greatly, going up to 130, 140, and 
falling to 80. In adults this fever of the excitation period may be 
wanting. At all times during the disease the pulse is very unequal in 
rhythm and the heart very excitable. The pulse may become slow and 
regular without any apparent reason, or may again become very rapid. 
Although the type of the fever is remittent and is often mistaken for 
remittent fever, it is subject to great variations. Three important 
symptoms besides the fever mark the onset of the excitation period — 
headache, vomiting, and constipation. The headache is severe, heavy, or 
lancinating ; and, although continuous, is varied by exacerbations, com- 
pelling outcries, or rubbing the head, or other manifestations of severe 
suffering. As the suffering is increased by light, the head is either 
buried in the bedclothes or turned to the wall, or the eyes are covered 
by the eyelids. The vomiting occurs a few times during the twenty- 
four hours, and is always without apparent cause ; the constipation 
persists obstinately ; the belly is hard and retracted. During the exci- 



TUBERCULAR MENINGITIS. 



607 



tation period, changes in the character and disposition which began in 
the prodromal period continue and are more pronounced — an exceeding 
fretfulness and hostility to those to whom they were much attached, 
developing. Not only the special but general sensibility is exalted ; 
all movements cause pain and loud expressions of suffering, and the 
least pinch, especially about the neck, excites exquisite pain. In the 
motor sphere the symptoms of excitation take the form of spasmodic 
movements of muscles, contractions, and rigidity, especially seen in the 
muscles of the members and of the neck. There will occur at this 
period also local convulsive movements, and not unfrequently general 
convulsions (eclampsia), with the usual phenomena. The stage of 
excitation due to the development of meningitis now begins to yield 
to the phenomena of depression due to the pressure of the fluid on the 
cerebral matter. Here, then, is a period during which the symptoms 
of irritation still linger, and the symptoms of depression are just mani- 
festing themselves — a mixed stage : paroxysms of pain and spasmodic 
and convulsive attacks are separated by periods of somnolence, during 
which there may be uttered the peculiar shrill, unearthly cry or shriek 
called the hydrocephalic cry. If attempts at walking are now made, 
the patient's movements are incoordinate and uncertain, and indeed 
it is impossible to preserve the equilibrium. Torpor now becomes the 
settled state, but still the patient can be roused to make an imperfect 
or monosyllabic reply to questions, lapsing back into a somnolent state 
as soon as the attention is no longer attracted. At this period the 
ocular changes are manifest : there are strabismus and double vision ; 
the pupils are often unequal. The countenance is pale, stolid, and 
expressionless. The retinal changes are very pronounced. Tubercles 
of the choroid can often be detected. At first the optic papillae are 
swollen, blurred, and indistinct, the veins are enlarged and tortuous ; 
but in the further progress of the case retrograde changes, ending in 
white atrophy of the disks, take place.* This mixed stage has a 
variable duration of a few days to a week or more, and is varied by 
illusory evidences of improvement, which often mislead the physician, 
and raise false hopes in the minds of the parents and friends. These 
appearances of improvement at this time consist in a more regular 
pulse, less somnolence, greater interest and attention to surrounding 
objects, playthings, etc. Indeed, it seems as if the morbid process Avere 
arrested, and that convalescence is about to be established ; but, while 
the most cheerful anticipations are indulged in, formidable symptoms 
suddenly appear. A general convulsion, it may be, occurs, or the mus- 
cles of the neck and spine become rigid, or local convulsions affect the 
members ; a mild delirium manifests itself ; the respiratory move- 
ments become very unequal in depth and irregular in rhythm, and 



* Allbutt on " The Ophthalmoscope," p. 112. 



608 



DISEASES OF THE NERVOUS SYSTEM. 



have at times a sighing character ; the pulse is equally irregular, be- 
comes slow, falling to fifty even, and there are marked variations in 
its volume and tension ; the temperature remains elevated, but pre-- 
serves its remittent type. The approaching stage of depression is now 
announced by the increasing somnolence, by the greater effort to excite 
the most transient and indefinite response ; light nor sounds no longer 
disturb the brain ; sensibility is no longer excitable ; the contractions 
of muscles are replaced by relaxation ; the urine is passed involun- 
tarily. When the stage of depression is fully established, no indica- 
tion of consciousness can be excited by any irritation, and the reflex 
movements of the eye are entirely abolished. The pupils now dilate ; 
the upper lids droop over the eyes ; the globe of the eye rolls from 
side to side (nystagmus) ; the pharynx becomes less and less respon- 
sive to the presence of food or drink, and finally no movements can 
be excited — only the slow, irregular pulse changing to a rapid and 
feeble pulse and the Cheyne-Stokes breathing manifest the signs of 
functional action. Males from accumulating mucus now obstruct the 
breathing, the pulse becomes more rapid and feeble, a cold sweat 
breaks out on the skin, the abdomen becomes full and prominent, the 
evacuations are relaxed and involuntary, and death occurs at last by 
protracted failure of respiration or by a convulsion. 

Course, Duration, and Termination.— The division into periods is 
an arbitrary arrangement, but useful as a means of indicating the 
variability of the symptoms and their relation to the morbid process. 
But the course of the disease is not always that above indicated : there 
are variations due to the age of the subject ; and tubercular meningitis, 
as a secondary disease, differs from the primary affection. In acute 
tuberculosis the cerebral symptoms are pronounced, but they are not 
those of tubercular meningitis. The form of the disease occurring in 
adults is secondary, usually to advanced pulmonary tuberculosis. 
There are no prodromal symptoms. In the midst of a pulmonary 
disease, the patient experiences intense headache, vertigo, delirium, 
often of a maniacal character ; there occur contractions of muscles, 
followed by paresis ; irregularity of pulse and respiration is noted ; 
and coma and insensibility succeed to wakefulness and delirium. Con- 
vulsions do not occur in the course of this secondary meningitis in 
adults. 

The prodromal period in the ordinary form of the disease has no 
fixed duration, and may continue for three months ; it is usually about 
three weeks, and is probably never absent if carefully inquired into. 
The period of excitation has a duration of about one week to two 
weeks ; the middle period may be protracted three weeks, but usually 
occupies one week ; the period of depression lasts from one to two 
weeks. Although a very few cases have been reported cured, it is 
held to be an incurable disease, and the termination fatal. The cases 



ACUTE MENINGITIS. 



609 



reported cured were, it is generally supposed, examples of simple not 
tubercular meningitis. The consideration of diagnosis and treatment 
will be taken up after the study of simple meningitis of the base and 
convexity. 

ACUTE MENINGITIS. 

Definition. — Acute meniyigitis consists in an inflammation of the 
pia mater and arachnoid, chiefly the former. It may be limited to the 
base — basilar meningitis^ or to the convexity — meningitis of the con- 
vexity. 

Causes. — Meningitis is derived by contiguity of tissue from disease 
in neighboring parts— disease of the internal ear, erysipelas of the face, 
malignant pustule, caries of the bones, traumatic injuries. It is then 
entitled secondary meningitis. It sometimes arises during the course of 
inflammation of serous membranes, acute rheumatism, puerperal fever, 
pyaemia, Bright's disease, by that which was formerly called a metas- 
tasis, and hence was designated metastatic meningitis. The primary 
form with which we are now chiefly concerned arises from the causes 
inducing congestion and overaction of the brain, as excessive intel- 
lectual effort, prolonged wakefulness, exposure to the direct rays of the 
sun, and alcoholic excess. The most common cause of meningitis is the 
deposit of tubercle, but this has been discussed in the previous chapter. 
The primary form is a rather uncommon malady. The disease is more 
frequent in men than in women, and is less common in children. 

Pathol Ogical Anatomy. — In the basilar form, the inflammatory 
changes are confined to the base, and consist of intense hyperaemia, 
followed by purulent and fibrinous exudation, covering the parts at 
the base as far back as the pons, and forward to the optic chiasm, and 
surrounding some of the nerves. The choroid plexus is intensely hy- 
perasmic, and the ventricles may be distended with fluid, compressing 
the hemispheres and flattening the convolutions. The ependyma of 
the ventricles becomes granular or undergoes thickening. Hydrocepha- 
lus is by no means present in all cases. In the meningitis of pyaemia 
and other septic maladies the fluid exuded is largely purulent, and mi- 
grating white corpuscles are found in great numbers in the exudation 
in the ventricles. In meningitis of the convexity the inflammation 
is excited by extension from the bones of the cranium, from caries 
of the petrous portion, from panophthalmitis, from erysipelas of the 
head, and carbuncle of the upper lip, etc., and is of the character 
manifested by the same process at the base. Pus is extensively infil- 
trated, especially along the course of the great vessels. The migrating 
white corpuscles invade the gray matter of the cortex, and pus-cells 
are contained in the fluid of the ventricles in large numbers. Although 
the morbid process may be confined to the convexity, yet in most 
cases the base is more or less invaded. 
41 



610 



DISEASES OF THE NERYOUS SYSTEM. 



Symptoms — There may or may not be a prodromal period, charac- 
terized by a rather violent headache, vertigo, and cerebral vomiting, 
lasting for a few hours or a day or two. The real onset of the disease 
is rather sudden, and, like other acute inflammatory diseases, begins 
with a decided chill followed by high fever — by a more intense and 
sustained fever than in other cerebral maladies. The pulse may be 
100, the temperature 103° or 104° Fahr. The face is flushed, the eyes 
are injected and swollen. There are from the beginning an intense 
headache, vertigo, nausea, and vomiting. When the morbid process 
is confined to the base, the mental symptoms may be very insignifi- 
cant, and consist of confusion of mind, or mild delirium toward even- 
ing or on awaking from sleep, but usually there are hallucinations and 
illusions, active delirium, sometimes furious and maniacal, and these 
are proper to meningitis of the convexity. During the period of exci- 
tation there are hyperaesthesia of the skin and contractions and spasms 
of the muscles of the extremities, and those innervated by the cranial 
nerves — hence the ocular defects and disturbances, twitchings of the 
facial muscles, rigidity and contraction of the spinal and cervical mus- 
cles, etc. The symptoms of excitation are soon succeeded by depres- 
sion. Early, besides the muscular incoordination and consequent ataxic 
aphasia, there occurs a true aphasia from deposits along the middle 
cerebral and consequent compression of the supposed language center. 
Delirium is succeeded by somnolence, gradually deepening into coma ; 
exalted sensibility (hypersesthesia) yields to loss of the senses of touch 
and pain ; spasms and contractions of muscles are replaced by paraly- 
sis. The pupil dilates. Early in the disease ophthalmoscopic exami- 
nation discloses choked disks and swollen veins, but the papillae rap- 
idly undergo atroj^hy. The eyelids drop down upon the eyes, and are 
swollen and prominent ; epistaxis often occurs. With the increasing 
pressure on the medulla oblongata, the pulse falls, then grows rapid 
and feeble, but the temperature continues at 103° or 104° Fahr. The 
respiration becomes irregular, sighing — of the Cheyne-Stokes type — 
and increasingly shallow. 

Course, Duration, and Termination.— The cases of meningitis pre- 
sent great variability in their course and in their duration : some are 
characterized by remissions — apparent improvement continuing for 
days, and followed by relapses. Again, the course and duration of 
other cases are much affected by the cause of the meningitis and the 
character of the coexistent malady. The duration may be stated as 
varying from one week to eight weeks. The usual termination is in 
death. Cures may be effected in which permanent damage has hap- 
pened, and a sense or a member remains only partly capable of func- 
tion ever after. Perfect cures have been reported, but a doubt of 
their genuineness must always be entertained. Before and immediate- 
ly succeeding death the temperature may rise to 105° and 106° Fahr. 



ACUTE MENINGITIS. 



611 



Diagnosis. — This question includes the differentiation of the several 
forms of meningitis, and the separation of meningitis from acute tu- 
berculosis, typhoid fever, tumor and abscess of the brain, encephalitis, 
cerebral hypersemia, uraemia, and disease of the labyrinth. Tubercu- 
lar meningitis is differentiated from the other forms by the history, 
by the simultaneous appearance of tubercular deposit in other organs, 
especially pulmonary tuberculosis, and by the presence of tubercles in 
the choroid. Acute hydrocephalus is distinguished from meningitis 
by the less degree of fever, by the predominance of the stage of de- 
pression, and, in the apoplectic and convulsive forms, by its more 
speedy termination, and by the absence of symptoms due to the impli- 
cation of the cranial nerves at the base. Meningitis in its various 
forms is distinguished from acute tuberculosis and typhoid fever by 
the symptoms of excitation of the brain, especially the convulsions, 
and subsequently by the ocular and other paralyses, the alterations of 
the retina, by the absence of the rose-spots, the absence of diarrhoea, 
and the presence of constipation. Meningitis is distinguished from 
tumors of the brain by its more rapid progress, more diffused symp- 
toms, and the presence of fever ; from abscess, by the absence of a 
period of latency after the symptoms of an inflammation ; and by the 
diffusion of the symptoms of depression. From cerebral hyperaemia, 
meningitis is differentiated by the higher temperature, longer dura- 
tion, and the symptoms of depression succeeding to a stage of excita- 
tion. In uraemia the temperature is usually below rather than above 
normal ; the urine is scanty and contains albumen, and there is or has 
been dropsy. Labyrinthine disease, even inflammation of the middle 
ear, may closely simulate meningitis, but the existence of ear-symp- 
toms and the absence of paralysis indicate the source of the symp- 
toms, which also begin with great violence. 

Treatment. — The head should be kept elevated ; the room dark and 
quiet, to exclude all sources of cerebral excitement. An ice-bag should 
be put to the head, the hair being previously removed. If a robust 
subject, leeches should be applied to the mastoid bone and to the nape 
of the neck. An active purgative should be administered at the out- 
set. If the temperature is high, the wet-sheet should be used two or 
three times a day, unless mental excitement is produced by it. If the 
patient is calm under its use, and if the temperature is lowered by it, 
the best results may be expected from it. The author has witnessed 
admirable results from the administration of the tincture of aconite- 
root (two drops) and the deodorized tincture of opium (five drops) 
every two hours during the stage of excitation. Bromide of potas- 
sium ( 3 ss.) and fluid extract of ergot ( 3 ss.), every four hours, are 
appropriate remedies to diminish the vascular excitement, but, in the 
author's experience, are not so successful as aconite and opium. If 
there be much cerebral excitement, good results are obtained from the 



612 



DISEASES OF THE NERVOUS SYSTEM. 



fluid extract of gelsemium, which may be added to the other remedies 
(TTtj every two hours). If the coDvulsions are numerous, bromide of potas- 
sium must be administered freely, and chloral given by the rectum. Dur- 
ing the whole duration of the disease up to coma, Lugol's solution (four 
to ten drops ter in die) should be administered, or the iodide of potas- 
sium if better borne. This remedy is especially serviceable in the tuber- 
cular form. During the stage of excitation, mustard-plasters should be 
applied to the forehead and neck several times a day, allowing them 
to remain en but a minute, or even less, until slight rubefaction is pro- 
duced. The author must decidedly condemn the practice of severe and 
protracted counter-irritation so often pursued in cerebral maladies. 
The remedies above advised must be discontinued when depression of 
function occurs — except the iodine solution or iodide of potassium. The 
best results are then obtained by small doses of quinine, with belladonna 
tincture or extract (two grains of quinine and one sixth grain of bella- 
donna extract every three hours). An occasional or spasmodic admin- 
istration of these remedies will not suffice— they must be persisted in. 
During this period careful alimentation is very necessary, and wine 
may be sometimes very serviceable, but its administration must be 
watched. The author feels it his duty to condemn the use of mercury 
in this disease. Experience has shown that it has no power to check 
the inflammation, and ptyalism enhances all the dangers. 



CHRONIC MENINGITIS. 

Pathogeny. — Chronic meningitis is characterized by the formation 
of membranous exudation, opacities of the arachnoid, adhesions be- 
tween the arachnoid and pia, and such firm attachment of the mem- 
branes to the brain that, in detaching them, the brain is torn. The 
morbid changes in the membranes, the formation of neo-membrane, etc., 
take place both at the convexity and at the base. In the latter situa- 
tion the cranial nerves are impinged on with the effect, first, of causing 
irritation, shown in pain and spasm of these nerves at their peripheral 
distribution ; and, second, loss or depression in function, exhibited in 
anajsthesia and motor paralysis. The lesions of chronic meningitis are 
found in old cases of mania, dementia, and dementia paralytica. The 
only causes known to have an effect in producing this disease are in- 
juries of the head, chronic alcoholism, and heredity. 

Symptoms. — So often associated with the mental disorders above 
mentioned, chronic meningitis is obscured and overlooked in the more 
pronounced symptoms of the associated malady. There are, neces- 
sarily, two classes of symptoms to be noted — those of irritation, those 
of depression : the former mean pain, spasm, or contraction ; the latter 
anaesthesia and paralysis. In the first group are headache, tinnitus 
aurimn^ vertigo, double vision, rigidity and contraction of the muscles 



ABSCESS OF THE BRAIN. 



613 



of the neck and spine, nausea and vomiting, irregular pulse, and a rhyth- 
mic breathing ; in the second, impaired mind, defects of speech, or 
aphasia, amaurosis (double optic neuritis), weakness, paresis, or paraly- 
sis of members or of groups of muscles, weak pulse, and sighing, shal- 
low, irregular breathing, paralysis of tongue, and paresis of pharynx, 
etc. The treatment is that of the acute form, except the use of the 
arterial sedatives. 

ACUTE ENCEPHALITIS— ABSCESS OF THE BRAIN. 

Definition. — By acute encephalitis is meant a suppurative inflamma- 
tion of the brain, and which is localized, not diffused. It may be pri- 
mary or secondary. 

Causes. — Notwithstanding certain stimuli, long acting, have been 
supposed to cause inflammation of the brain, the facts do not warrant 
this supposition. These supposed causes are, prolonged mental effort, 
exposure to the sun's rays, venereal excesses, alcoholism, etc. The 
affection is more common in men than in women (nine to four), and 
occurs at all ages, but especially at the most active period in life — from 
puberty to fifty years of age. The secondary is probably the only 
form of the disease, and arises from injury and contusions of the 
head ; disease of the nasal fossjB, frontal sinuses and orbit ; caries of 
the cranial bones, and especially of the petrous bone, from disease of 
middle ear. Besides traumatism, the most frequent cause is caries of 
the bones. Rarely encephalitis has occurred in the course of acute 
infectious diseases, and more frequently from infective emboli. 

Pathological Anatomy. — The points of inflammation are always 
circumscribed, and vary in size from an almond to an orange. They 
may be multiple, or occupy several parts at the same time, but this is 
not usual, and when so the individual collections are small. The usual 
position of the inflammation is in the corpora striata, optic thalami, the 
gray matter of the cortex, the cerebellum, the abscess forming in the 
white matter of the hemispheres. They are said to be more frequent in 
the left than in the right hemisphere. The abscesses may or may not 
be, but usually are encysted, or inclosed in a limiting membrane. They 
are irregularly circular in shape, and when not encysted the walls of 
the cavity are extremely irregular^ masses of breaking-down cerebral 
matter projecting into the pus, which is also diffused into the surround- 
ing textures. The abscess is composed of rather thick, greenish, odor- 
less, but sometimes fetid pus and disintegrated remains of the cerebral 
tissue. The initial change at the site of the abscess is hyperaemia ; 
minute extravasations take place (capillary haemorrhages), giving to 
the inflamed area a dark, reddish color, whence the term red softening 
migration of white corpuscles, diapedesis of some red corpuscles, and 
exudation of serum holding albumen and fibrin in solution, occur 



614 



DISEASES OF THE NERVOUS SYSTEM. 



simultaneously. The brain-tissue, being soft and easily broken up, is 
rapidly disassociated, and its elements disintegrated, and in a short 
time a soft, pultaceous red mass results, which more and more assumes 
a purulent character, becoming first reddish-yellow, then yellow or 
greenish-yellow, ultimately almost white. The limiting membrane 
consists of a connective-tissue material constructed from the neuroglia. 
The part which the cells of the neuroglia and the cellular elements of 
the gray matter (which most readily takes on the suppurative inflam- 
mation) assume in the process is not definitely known, as Rindfleisch 
frankly admits. The encysted abscess may take either of two direc- 
tions : the pus may be gradually absorbed, the cyst undergoing calci- 
fication, or, after a quiescent period, set up a new disturbance, ending 
in death, which is vastly more common. When the abscess approaches 
the surface, meningitis is excited and adhesions of the membranes may 
take place to neighboring parts and to the walls of the abscess. The 
injury caused by an abscess is not limited to the portion of brain in- 
flamed, but the neighboring territory is in the condition of collateral 
hypersemia and oedema. 

Symptoms. — There are three stages in the course of encephalitis: 
inflammatory ; period of silence ; coma. ~Not all conform to this, and 
hence variations must receive some attention, and the symptoms are 
much influenced by the locality of the lesions. There are symptoms 
common to cerebral abscess, and symptoms only produced by abscess 
in certain situations. The symptoms of the inflammatory stage are 
headache, vertigo, noises in the ears, double vision, strabismus (tempo- 
rary), sometimes affections of speech, numbness and tingling in certain 
members, sudden muscular cramps, incoordination of muscles in walk- 
ing,, sometimes nausea and vomiting without cause, irritability of the 
bladder, etc. If these symptoms have followed a blow on the head, or 
have come on in the course of an otorrhoea, or of a long-standing affection 
of the nose, attention should be directed to the probable development 
of an encephalitis. After some days or weeks of these symptoms an 
apoplectic seizure may occur, or convulsions of an epileptiform charac- 
ter or delirium. Rigidity and contraction of one side or of both sides 
are found to exist, succeeding the seizure, the period of unconsciousness 
being short; also strabismus, double vision, and embarrassment of speech 
(amnesic aphasia). Sometimes the members contracted, sometimes on 
the other side, are attacked by clonic spasms, and occasionally there 
are general convulsions of an epileptiform type. The intellect is not 
always disturbed at the beginning, but there may be acute maniacal 
delirium or simply confusion of mind. It rarely happens that paralysis 
— a symptom of depression — ajDpears as an initial symptom, and, if so, 
it may be safely assumed that the symptoms of irritation escaped 
notice. Heightened general sensibility — ^hyperaesthesia — is present in 
the parts, the seat of contractions or spasms, but ansesthesia accom- 



ABSCESS OF THE BRAIN. 



615 



panies the period of depression. These symptoms of the inflammatory 
stage are attended by fever, not of a special type, the thermometer ris- 
ing to 102° or 103° Fahr. The pulse is at this period full and strong. 
The urine is scanty and high-colored, ]N"ausea and vomiting are very 
persistent symptoms in some cases, and occur to a greater or less extent 
in all, and this statement is equally true of constipation. The inflam- 
mation stage proceeds to the formation of pus, and includes the incap- 
sulation of the abscess. When the purulent elements are diffusing 
through and disassociating the nervous tissue, the symptoms of depres- 
sion succeed to excitation. The formation of pus may take place in 
five or six days, certainly within ten. When this period is reached, 
mental excitement is succeeded by somnolence passing into stupor, 
contractions and rigidity yield to relaxation and paralysis, the pulse 
becomes slow, the respirations shallow and irregular, the coma deep- 
ens, all reflex movements are suspended, and death ensues. Excluding 
the prodromic period, the whole course of the disease may have been 
completed within seven to ten days. Death may also occur in these 
cases in the apoplectic coma, in the convulsions, or in the acute delirium 
which marks the onset of the inflammatory period. The cases do not 
all pursue the course just indicated. When the stage of depression 
is reached there may be a period of improvement, or the case may con- 
tinue with the hemiplegia, the local paralysis, at a fixed point, the gen- 
eral condition, however, becoming much better. If the abscess is so 
situated in the hemispheres as not to involve the motor or sensory 
tracts, the symptoms of excitation will consist of delirium, epilepti- 
form attacks, etc., and fever. The fever, as the author has witnessed, 
and verified the observation by post-mortem examination, may be 
intermittent, and, although somewhat irregularly so, be regarded .as a 
genuine intermittent, and treated with quinia. The period of silence 
is rather a remission than a complete cessation of all morbid phenomena. 
As already indicated, some weakness or paralysis, lowered sensibility, 
defect of language, or impairment of mind remains. The abscess has 
been inclosed in its limiting membrane, and cut off from present mis- 
chief. In one case observed by the author, the patient so far improved 
in condition as to resume his occupation after a serious illness, but he 
still suffered from headache and vertigo and dimness of vision, and he 
experienced a remarkable change in his mental state : having been 
silent and reticent before, he became extremely talkative and commu- 
nicative. This fact is all the more remarkable, since the abscess occu- 
pied the right anterior lobe. The period of silence is of variable dura- 
tion, lasting from a few weeks to several months, during which the 
patient may be cut off by some intercurrent disease. There seems to 
be a relation between abscess of the right hemisphere and pneumonia. 
This period may be suddenly terminated by the abscess bursting into 
the ventricle, or at the surface of the hemisphere, which will be an- 



616 



DISEASES OF THE NERVOUS SYSTEM. 



nounced by violent convulsions, coma, and insensibility. , Usually the 
end of this period is announced by an attack of intense headache, soon 
followed by drowsiness, and terminating in coma, or by convulsions 
and coma, or more slowly by a new meningitis, Not all cases of en- 
cephalitis pursue the defined course just described. The formation of 
the abscess may be quite latent, and no symptoms attract attention until 
convulsions and coma announce the end. Various forms are described 
by systematic writers, thus : the meningeal form, in which the fever 
is high, the delirium acute ; the comatose form, in which the symp- 
toms of excitation have been latent, and the early development of 
coma, dilated pupils, convulsions, and muscular resolution, indicate 
the extension of suppuration and early death ; the paralytic form, in 
which limited abscesses occur in the motor ganglia at the base, and 
paralytic symptoms — hemiplegia, aphasia, and ocular disturbances — are 
present ; the apoplectic form, in which sudden unconsciousness, fol- 
lowed by rigidity and paralysis, is the prominent feature ; and the 
epileptic form, characterized by the predominance of eclampsia, suc- 
ceeded by paralytic disorders. 

Course, Duration, and Termination.— ^Notwithstanding the variabil- 
ity of the symptoms, encephalitis pursues a course not without uniform- 
ity. From the reception of the injury until the development of active 
symptoms is the prodromal period, of uncertain duration, from a few 
days to several weeks, even months. When the inflammatory process 
actually begins, the duration of the stage is about a week. Death may 
occur at this period. The period of silence is very variable also, and 
may be a few weeks' to several months' duration. A few hours or a 
day or two end this stage. The usual termination is in death. Ke- 
covery has taken place during the stage of inflammation, and by the 
discharge of pus spontaneously or by puncture. 

Diagnosis. — The diagnosis involves the question of the seat of the 
abscess and the differentiation of abscess from tumor, from cerebral 
hemorrhage, and from meningitis. If the abscess is situated in the 
hsemispheres above the motor ganglia, there will be delirium and con- 
vulsions, and not contractions or paralysis ; and, if in the region sup- 
plied by the left middle cerebral artery, amnesic aphasia will be present. 
If the abscess forms in the motor ganglia at the base, hemiplegia will 
be the prominent symptom ; or paraplegia, should there be an abscess 
on both sides. If the abscess forms in the middle fossa of the skull, 
about the sella turcica, and involves the crus cerebri, there will be 
paralysis of the extremities on the opposite side, and of the third nerve 
on the same side. If the abscess occurs in the neighborhood of the pons, 
so as to impinge on one side, there will be a crossed paralysis of the 
facial on the same side and of the members on the opposite side. Ab- 
scess of the cerebellum gives rise to incoordination of muscular move- 
ments, vertigo, vomiting, amaurosis, and convulsions. In abscesses of 



INTRA-CRANIAL TUMORS. 



617 



the base, the cavernous sinus is compressed, and hence there will be 
present swelling of the eyelids, injection of the conjunctiva, and epis- 
taxis. On ophthalmoscopic examination, the retinal veins are swollen, 
tortuous, and the disks are congested and stuffed (choked disks), but, 
in the further progress of the cases, white atrophy ultimately results. 
In abscess of the base and cerebellum, the retinal congestion occurs 
earlier and is more pronounced. There is no symptom of tumor which 
may not occur in abscess, but still a distinction may often be made. 
Tumor develops more slowly than abscess, and is unaccompanied by 
fever. The symptoms are continuous in cases of tumor, and there is 
no period of silence. Abscess is often connected with injury, with 
caries of the bones, disease of the ear and nose ; tumor develops with- 
out any cause. Between the apoplectic form of abscess and cerebral 
haemorrhage there is no well-marked distinction except as to termination, 
which resolves the doubts. The other forms of abscess do not come 
into relation to cerebral haemorrhage. Abscess of the cortex and menin- 
gitis present the same symptoms of irritation followed by depression, 
but in the latter there is no period of silence followed by relapse. 

Treatment. — The stage of inflammation requires active measures to 
prevent further mischief, as the remedies already advised for acute 
meningitis. Ergot, quinine, and chloride of barium (liq. barii chloridi 
TTi XX every four hours) are the most efficient means of preventing the 
migration of the white corpuscles and the diapedesis of the red. When 
suppuration occurs, it is good practice to check the formation of pus, 
and the collateral oedema and hypersemia, by full doses of quinine. The 
propriety of trephining, or of puncturing the brain, to favor the exit 
of pus, is a question of purely surgical interest, into the discussion of 
which we do not purpose to enter. 

INTRA-CRANIAL TUMORS. 

Definition. — The term mtra-cranial tumor is a more correct desisr- 
nation than cerebral tumor, for it includes all neoplasms so situated as 
to affect the contents of the cranium. The term cerebral tumor takes 
into consideration, if restricted to its proper meaning only, tumors of 
the cerebrum, and not those of the meninges, of the vessels, etc. By 
the term tumor in this connection are intended all kinds of growths or 
outgrowths, and it is not confined to its merely technical signification. 

Causes. — Intra-cranial tumors are usually divided into four groups ; 
the vascular ; the parasitic ; the diathetic ; and the accidental. Tumors 
are more common in men than in women, simpty because men are 
more exposed to the influences producing them. Injuries excite osseous 
and connective-tissue hyperplasia, and a violent strain may be the 
cause of an aneurism. The diathetic tumors are in part transmitted 
by inheritance, in part acquired. 



618 



DISEASES OF THE NERVOUS SYSTEM. 



Pathological Anatomy. — Of 551 cases of aneurism in various parts 
of the body, only seven were intra-cranial.* The arteries of the base 
only are concerned, for a miliary aneurism is not a tumor in the sense 
in which that term, is here used. The internal carotid and its branches 
are most frequently affected ; in a total of 172 cases, 116 were of these 
vessels, and 53 were of the vertebro-basilar arteries. Taking indi- 
vidual arteries, we find that in a collection of 142 cases there were 
forty-one of aneurism of the middle cerebral, forty of the basilar, 
twenty-three of the internal carotid, fourteen of the anterior cerebral, 
eight of the posterior communicating, seven of the vertebral, four of 
the posterior cerebral, three of the inferior cerebellar, and two of the 
anterior communicating. As respects the side of the brain, the left 
is more frequently affected by aneurism. In a collection of sixty 
cases, thirty-five were on the left and twenty-five on the right side.f 
As regards size, intra-cranial aneurisms vary greatly, those of the an- 
terior and middle cerebral artery attaining to the greatest size. From 
a pea to a pigeon's-egg is the usual size, but they may attain to the 
dimensions of a hen's-egg. The parasitic tumors consist of the cysti- 
cercus celluloses, or the echinococcus. The former are small vesicles 
the size of a pigeon's-egg, composed of a transparent wall and pellucid 
contents. They are found often in large numbers in the gray matter 
of the hemispheres, in the pia mater, and, as the author has seen, on 
the floor of the fourth ventricle. The echinococcus cyst is larger, often 
solitary, and never exceeding three to five. It has a tougher investing 
membrane, but transparent contents in which can be seen the scolex 
with its booklets (Davaine). The diathetic tumors are cancer, syphi- 
lis, and tubercle. Cancer is a very frequent form of tumor, and, al- 
though at one time was supposed never to occur as a primary disease, 
is now known to be often primary. According to the statistics of Le- 
bert, of forty-eight cases of cerebral cancer, thirty-five were primary. 
According to Bacon,| only ten in seventy-three cases were primary. 
Ogle § finds that thirteen out of twenty-five occurred in the brain alone. 
When secondary, there are several nodules ; when primary, a single 
one, whic'i is usually quite separated from the tissue in which it is im- 
bedded. The largest tumors are those growing in the hemispheres, 
an example of which the author saw, having the dimensions of the 
closed fist. The form is usually encephaloid, rarely scirrhous, still more 
rarely colloid and melanoid. The position of the cancer, named in 

* "Transactions of the Pathological Society," vol. vii, op. cit. 

f The above statistics of intra-cranial aneurism were obtained from an article on "An- 
eurism of the Brain " by the author, published in the " American Journal of the Medical 
Sciences," October, 1872. The statistics of Lebert, of Durand, and of Gougenheim, wer« 
analyzed in this article. 

X "On Primary Cancer of the Brain," London, 1865, pamphlet, 

§ Reynolds's " System of Medicine," vol. ii. 



INTRA-CRANIAL TUMORS. 



619 



the order of relative frequency, is the hemispheres, the cerebellum, 
corpus striatum, optic thalamus, and pons. Cancer of the orbit, of the 
scalp, or of the cranial bones, may grow inwardly to the brain ; on the 
other hand, cancer of the brain tends to develop outwardly. The 
form of syphilitic tumor is a gumma of the dura, and may occur at 
the convexity, but its favorite site is in the middle fossa of the skull, 
about the sella turcica. They do not attain to great dimensions, rarely 
exceeding a walnut, and more frequently having the size, as also the 
shape, of an almond. H^^erc^e-masses consist of an aggregation of 
cheesy nodules, and vary in size from a pea to a walnut. The most 
frequent situations are the cerebellum and the hemispheres, and much 
Ifiss often the corpus striatum and optic thalamus. The group of intra- 
cranial tumors called accidental contains glioma, sarcoma, steatoma, 
myxoma, psammomata and exostoses, Gliomata develop from the 
neuroglia, and are hard or soft, according to the quantity of granular 
and cellular contents and fibrillge. They are very vascular, and hence 
may be accompanied by considerable haemorrhage. They are found 
in the hemispheres, in the gray and white matter, and may be attached 
to the membranes. Of the sarcomata, there are several varieties ; they 
may adhere to the meninges, or develop in the hemispheres, or in the 
motor ganglia, at the base. Lastly, the cholesteatoma, which grows 
from the arachnoid or pia mater, and is found on the hemispheres and 
in the posterior fossa, attains by the aggregation of several smaller 
tumors sometimes to the size of a goose-egg. A growing tumor affects 
the parts in its immediate neighborhood by the irritation which its 
presence excites, and by destruction of tissue effected by pressure. 
Neuritis and ultimate softening and disintegration of nerves impinged 
on, inflammation, absorption, and softening of the adjacent portion of 
cerebral matter, are pathological results of the proximity of a tumor 
to the intra-cranial organs. Besides the local effect, a growing tumor 
increases the pressure of the organs, and causes a displacement of the 
movable contents of the cavity, the blood and cerebro-spinal fluid, and 
an approximation of the perivascular lymph-spaces. Pressure on the 
sinuses interferes with the venous circulation. 

Symptoms. — The symptoms produced by intra-cranial tumors are 
divisible into two classes : those common to tumors in all situations ; 
those caused only by tumors in particular situations. In the first 
group are headache, vertigo, amaurosis, convulsions, and mental dis- 
orders ; in the second, aphasia, strabismus, ocular paralyses, and hemi- 
opia, tic- douloureux, facial spasm or paralysis, deafness, incoordination, 
vomiting, crossed paralyses, etc. Headache is of so persistent and 
violent character that Ladame* holds it has high diagnostic impor- 
tance. It consists of paroxysms of acute pain and a constant feel- 
ing of uneasiness. The pain is increased by jarring the head, by 

* " Symptomatologie und Diagnostik dcr Hirngeschwiilste," Wiirzburg, 1865. 



620 



DISEASES OF THE NERVOUS SYSTEM. 



tapping even gently, and by a full inspiration. Sometimes the posi- 
tion of the pain indicates the site of the neoplasm ; as pain in the 
forehead, when the tumor is in the anterior lobe ; in the occiput, 
when the tumor is in the cerebellum. Vertigo comes on usually some 
time after the headache, and is present to a greater or less extent in 
all cases, but is more pronounced in the case of tumor of the cere- 
bellum. Slight fainting-fits, with or without the most transient loss 
of consciousness, and accompanied by intense vertiginous sensations, 
occur in many cases. Early in the development of the tumor the 
vertigo subsides on assuming the recumbent posture and closing the 
eyes, but later the vertigo comes on severely when the position is 
horizontal, the bed and all objects being in more or less rapid mo- 
tion. In advanced cases, the vertigo is so severe as to prevent walk- 
ing, or at least to render it difficult and uncertain. Amblyopia and 
amaurosis are also symptoms of tumor in any situation, for, as Hugh- 
lings Jackson well says, " so far as the production of optic neuritis 
by intra-cranial disease is concerned, the position of the disease seems 
to be of little consequence, and there is nothing very peculiar in its 
nature, except that it is usually coarse." Graefe held that the retinal 
changes were due to direct pressure on the cavernous sinus, the re- 
turn of blood from the orbit being thus prevented, but Lancereaux 
and others demonstrated that the pressure was not sufficient to do 
this in the case of many tumors situated at a distance. Neuro-reti- 
nitis, then, is a general symptom of intra-cranial tumor, but the retinal 
and orbital changes may also have special significance. Convulsions, 
local and j)artial, may furnish topographical indications, but general 
convulsion may accompany tumor in any situation, unless we except 
the pons Varolii, on the dictum of Ladame. Greater or less depart- 
ure from a healthy mental state is observed in all cases of tumor, 
and those involving the gray matter probably affect the mind more, 
but actual insanity has been observed in about one third only. In 
many cases, changes of disposition occur, usually in the way of morose- 
ness, irritability, and depression ; in others, the faculties seem enfee- 
bled, the power to apply the mind to any intellectual effort wanting : 
but the author has seen a case in which the patient, a clerk, developed 
a great capacity for the acquisition of languages during the time when 
the tumor, which occupied the posterior lobe of the left hemisphere, 
was forming. Eccentricities of conduct, delusions, and various other 
forms of mental derangement, accompany tumors of the brain, and a 
considerable proportion of such cases enter asylums for the insane. 
The symptoms which serve to indicate the position of the neoplasm 
are very important, and often extremely characteristic. The existence 
of amnesic aphasia — loss of the memory for words — strongly implies 
lesion of the left anterior lobe, fissure of Sylvius or island of Reil, or 
of the parts supplied by the left middle cerebral. A tumor of the cor- 



INTRA-CRANIAL TUMORS. 



621 



tex of either hemisphere may give rise to convulsive movements in the 
hand and arm of the opposite side, with or without general convulsions 
and loss of consciousness, and, if posterior, will involve sensibility as 
well as motility. A tumor impinging on the motor centers (corpus 
striatum, thalamus opticus, etc.) will produce first, irritation — spasmodic 
contraction and rigidity on the opposite side, and next depression by 
destruction of tissue — paralysis on the opposite side of the body. A 
tumor so situated as to impinge on the crus cerebri and the third nerve 
will produce symptoms differing according to the injury done ; if the 
result is irritation, irregular movements of the eye (nystagmus) on the 
same side, and rigidity and contraction in the muscles of the opposite 
side of the body ; if the result is destruction of tissue, there will be 
ptosis, convergent strabismus, and dilated pupil in the eye of the same 
side, and paralysis of the muscles on the opposite side of the body. 
If a tumor is so situated as to compress the optic nerve at the outer 
side of the chiasm, the field of vision will be narrowed to a degree cor- 
responding to the extent of the injury, and destruction of the chiasm 
would cause blindness. Irritation of the olfactory would give rise to 
strang-e smells, and destruction of the nerve to loss of the function. 
Tumors at the base may involve several cranial nerves, causing dis- 
turbances of great significance, either of irritation or loss of function. 
If the fifth nerve is irritated, tic-douloureux will be the result ; but, if 
the nerve is destroyed, there will be anaesthesia of all the j^arts to 
which the nerve is distributed. A tumor of the pons can be diagnos- 
ticated by the implication of the fourth, fifth, and sixth nerves on the 
same side, and by disorders of motility and sensibility on the opposite 
side, and by the absence of convulsions (Ladame). A tumor of the 
medulla oblongata causes disturbances in the important functions 
whose centers are located here — in speech, deglutition, respiration — 
causes disorders of sensibility and motility on the opposite side and 
of the face on the same side ; causes vomiting, constipation, and 
paralysis of the bladder, etc. Tumors of the corpora quadrigemina 
affect the motions of the eyes, set up double optic neuritis, and cause 
paralysis on the opposite side of the body. Tumors of the cere- 
bellum disorder the function of coordination, especially of those move- 
ments requiring the eyes to guide them, cause excessive vertigo, 
and difiSculty in maintaining the upright position, optic neuritis and 
early extinction of vision, and general convulsions. Tumors at the 
base, by pressure on the cavernous sinus, interfere with the return 
of blood from the facial vein, and cause swelling of the eyelids, bleed- 
ing at the nose, and fullness about the orbit. A growing tumor, 
by displacing the cerebro-spinal fluid through the internal and ex- 
ternal sheath of the optic nerve, renders the eye more prominent, 
and, by pressure on the cavernous sinus, maintains congestion of the 
orbital and retinal veins ; and hence, although retinitis occurs when 



622 



DISEASES OF THE NERVOUS SYSTEM. 



tumors are in the hemisphere anywhere, it will develop earlier and 
more severely in the case of tumor at the base. It has been ascer- 
tained that considerable atrophy of the optic disks is not incompatible 
with fairly good vision. The general condition of the subjects of in- 
tra-cranial tumor may be very good. When there is vomiting, there 
will be wasting from an inability to retain the necessary aliment. If 
the tumor is cancer, the peculiar earthy hue, the wasting, and emacia- 
tion will soon be manifest. 

Course, Duration, and Termination. — Obviously, there can be no 
uniformity in the course of tumor. The symptoms are, at first, very 
indefinite, and, in the case of some of them, at least months are occu- 
pied in developing any well-defined ailment. A persistent headache, 
vertigo, alterations of demeanor, are first noticed, and gradually the 
character of the case becomes known. Tumors situated in parts of the 
brain that are well called " indifferent " may never cause characteristic 
symptoms, but usually now a correct diagnosis may be made if the 
case is thoroughly evolved. The duration of tumor varies from two 
to three months, up to five or more years. Unless the tumor is syphi- 
litic, or possibly aneurismal, there can be but one termination. Some 
end in a convulsion, or rather in the secondary coma which follows it ; 
others are cut off by an intercurrent disease, and notably pneumonia, 
or by cerebral haemorrhage, or by acute meningitis. Aneurism ter- 
minates by rupture, unless by treatment its consolidation may be ef- 
fected. Before the access of the final coma a remarkable degree of 
somnolence is observed in some cases, sleep continuing for several days 
at a time uninterruptedly. 

DiagnosiSo — The determination of the position of the tumor has 
been sufficiently considered. Can a diagnosis be made of its nature ? 
Aneurism occurs in adults or the old ; in those w^ho continue to have 
good health, and who are not affected by a diathesis or an hereditary 
ailment. Vomiting is not usual ; the cranial nerves are early para- 
lyzed, and on the same side as the tumor ; the mental functions are 
not often affected ; epileptiform seizures do not occur, and the termi- 
nation is by an apoplectic attack. An aneurism of the internal ca- 
rotid within the carotid canal will cause protrusion of the eye by 
obstruction of the cavernous sinus, and may be accompanied by an au- 
dible hruit. A tubercular tumor is usually accompanied by the evi- 
dences of tubercular deposit elsewhere. The subject is young, and 
evidences of hereditary taint may be present ; it is situated deeply, 
often in the indifferent districts, and does not produce disturbances in 
the cranial nerves. Syphilitic gummata have a tendency to form in 
the middle fossa, and to affect the crus cerebri and third nerve, and 
are usually coincident with external lesions. Echinococci or cysti- 
cerci are accompanied by numerous epileptic attacks, at first without 
any injury, but subsequently the mind becomes torpid, and passes 



APHASIA. 



623 



into dementia. Local paralysis and hemiplegia are uncommon. The 
distinctions between tumor and abscess have been given in the article 
on abscess. The differentiation between obstruction of the cerebral 
vessels and tumor may often be a matter of extreme difficulty. Tu- 
mor may appear at any age ; thrombosis is usually a disease of 
advanced life. Thrombosis is accompanied by and due to chronic 
arteritis ; tumor is not related to general arterial changes. Tumor is 
charactei'ized by intense headache ; thrombosis by less severe and per- 
sistent. Tumor is generally accompanied by epileptiform attacks ; 
thrombosis by apoplectic. Tumor affects the cranial nerves, and 
causes localized paralysis ; thrombosis never produces such results. 

Treatment. — There are two remedies which ought always to be used 
- — iodide of potassium and ergot ; for, although only syphilitic and 
possibly aneurismal tumors are remediable, the case under treatment 
may be one of them. Scruple-doses of the iodide of potassium should 
be given until iodism is induced. If no improvement is then mani- 
fest, it need not be continued. A drachm or two of the fluid extract 
of ergot four times a day may properly be given for several weeks 
succeeding the iodide. The repetition of these remedies will depend 
on the results of their first administration. They may effect a cure of 
the syphilitic and vascular neoplasms. 

APHASIA. 

Definition. — Inability to use spoken language or to give vocal utter- 
ance to ideas is designated aphasia. The defect may consist in a loss 
of memory of the words by which ideas are expressed, when it is called 
amnesic aphasia ; it may consist, not in f orgetf ulness of the words, but 
in an inability to combine the different parts of the vocal apparatus for 
vocal expression — ataxic aphasia. When the defect involves written 
language, and consists in an inability to recognize and make the signs 
by which ideas are communicated in written language, it is named 
agraphia^ and this may be either amnesic or ataxic — ^the former being 
a mental defect, the latter an affection of the muscular apparatus, 
known as writer's cramp. Amnesic aphasia exists to a variable extent, 
and may, indeed, involve but a limited number of words. Paraphasia 
is a term proposed by Kussmaul * to signify the mental state in which 
the wrong words are used, or unintelligible expressions employed to 
express the idea. There may also be a paragraphia — a state in 
which wrong or meaningless written signs may be used to express the 
idea. 

Pathogeny. — Aphasia and its various modifications are associated 
with a number of intra-cranial lesions ; with occlusion, either by throm- 
bosis or embolism of the vessels ; with cerebral haemorrhage ; with 
* Ziemssen's '* Cjclopcedia," op. cit. 



624: 



DISEASES OF THE NERVOUS SYSTEM. 



encephalitis and abscess ; witli meningitis ; with the various torms 
and varieties of tumorg ; and it may be a merely mental and moral 
condition. Associated with so many and varied maladies, and occa- 
sionally existing alone, as the sole evidence of disease it is necessary to 
give the subject independent and separate consideration. We can not 
occupy space with an extended historical account of the progress in 
the knowledge of this peculiar condition, but we may state some facts, 
and begin by saying that to Gall unquestionably belongs the credit of 
first suggesting the position of the language faculty. He says, " I re- 
gard as the organ of verbal memory that cerebral part which rests on 
the posterior half of the roof of the orbit." * Thomas Hood, quoted 
by Hammond,f so long ago as 1822 described accurately a case of apha- 
sia. Bouillaud published a work in 1825 to prove the correctness of 
Gall's doctrines that the language faculty was situated in the anterior 
lobes. Marc Dax in 1836 made the remarkable statement that, in cases 
of aphasia, the paralysis was on the right side and the lesion on the 
left, thus limiting the seat of the language faculty to the left frontal 
lobe. The next and most important step was that taken by Broca in 
1861, who sought to prove by cases that " the integrity of the third left 
frontal convolution, and perhaps also the second, is essential for the de- 
velopment of the power of articulate speech." The observations on man 
seem to be confirmed by the experiments of Ferrier ^ and Fritsch and 
Hitzig, which show that electric irritation of a corresponding part in 
animals is followed by " alternate opening and closure of the mouth, 
with movements of the tongue." It seems to be now pretty definitely 
settled that lesions of the region supplied by the left middle cerebral 
artery, notably the island of Reil, the third convolution, and the neigh- 
boring part of the corpus striatum, are those accompanied by the va- 
rious forms of derangement included under the term aphasia. Hence 
it is that right hemiplegia and aphasia are so often associated. First 
in point of importance are lesions of Broca's convolution, next those 
of the island. Why the left hemisphere should be alone the seat 
of such a faculty, and not the right, has received various explana- 
tions, but that offered by Broca is probably the most nearly true — that 
the left hemisphere is earlier and more rapidly developed, receives 
more blood, and is therefore first and chiefly instructed, whence the 
greater skill and education of the right hand. Cases of left-handed 
persons becoming aphasic from disease of the right hemisphere have 
been reported. There are cases of aphasia in which the power to 
write correctly is retained — aphasia without agraphia. In other cases 
there is an absolute inability to communicate ideas by written signs, 
all attempts resulting in a meaningless scrawl. The two functions 

* Gall's "Works," vol. v, p. 11, translated by Winslow Lewis, M. D. 
f "Diseases of the Nervous System," op. cit , p. 178, sixth edition, 
i "Functions of the Brain," American edition, 1816, p. 143. 



APHASIA. 



625 



must therefore possess different centers and yet be in close proximity. 
Sign-speech, or the power to express ideas by signs, or sign-language, 
may or may not be simultaneously affected with the language faculty. 
As patients may or may not be conscious of the defect, there are con- 
sequently an amnesic amimia and an ataxic amimia. As amnesic 
aphasia may coexist with retention of the power of written language, 
by which the intellect may be tested, it has been demonstrated that 
the existence of aphasia is not incompatible with the full possession of 
the intellect in all other respects. A number of cases have now been 
reported in which amnesic aphasia was the sole lesion. The impor- 
tance of this observation, from the medico-legal point of view, is very 
great. On the other hand, it is generally true that the mind is weak- 
ened or impaired in other respects, so that the presence of aphasia is 
prima facie evidence of mental impairment. Aphasics are often very 
curiously damaged. A musician could not read the musical notes, but 
could play by ear ; on the other hand, Lasegue saw a musician with 
both aphasia and agraphia, who could write down notes that he heard 
(Kussmaul) ; others can not count money, or distinguish the uses of 
table-utensils. 

Course, Duration, and Termination.— The forms of aphasia pursue 
a course parallel to the malady with which they are associated, as a 
rule, but sometimes aphasia ceases before the disease, or continues 
after the disease has disappeared. Aphasia may be hysterical or due 
to curable disease, as syphilis, or it may be produced by reflex disturb- 
ance of function, as parasites in the intestines, or constipation. The 
duration will be brief under these circumstances, and the termination 
be in recovery, if right means are used. As regards the influence of 
permanent lesions, the results depend somewhat on age, for in chil- 
dren extensive injuries to the language center may be overcome by 
training, but in the aged limited lesions are fixed in their effects. 
Simple amnesic aphasia is more favorable, and ataxic aphasia is less 
favorable, as regards the prospect of recovery. The longer the con- 
dition of aphasia has existed, the less the prospect of recovery. The 
case is still less favorable when the aphasic state is increasing pari 

' passu with the disease on which it depends. 

Treatment. — The local disease must be removed if of a curable 
kind. If the case is one in which aphasia persists after the disease on 
which it depended has been removed, much may be done by suitable 
training. An admirable example of the results which can be obtained 

I by rightly directed effort is that of Bristowe,* of a Canadian in St. 

■ Thomas's Hospital, perfectly aphasic, whose speech was entirely re- 
stored in eight months by a course of carefully conducted speech-les- 

I * The Lumleian Lectures, on the "Pathological Relations of Yoice and Speech," 

i London "Lancet," June 21, 1879. 
42 

ti 
( 



626 



DISEASES OF THE NERVOUS SYSTEM. 



sons given by Dr. Bristowe. These Lumleian lectures deserve the 
attentive study of those who desire to have a truly scientific and phil- 
osophical knowledge of the subject. 

VERTIGO. 

Definition. — Vertigo is not properly a substantive disease, but it 
may be the only symptom of the morbid state to which it is referable. 
It is a subjective state, in which the individual affected, or the objects 
about him, seem to be in rapid motion, of a rotary, circular, or to-and- 
fro kind. In common language vertigo is known as dizziness. 

Pathogeny and Symptoms. — Vertigo may arise from centric or ec- 
centric causes ; hence it may be cerebral, auditory, cardiac, or stom- 
achal. One form of epilepsia mitior is vertiginous, or the manifesta- 
tion of the seizure consists in an attack, more or less violent, of vertigo. 
Other affections of the brain have the symptom vertigo at various times 
in their course. These have been, or will be, alluded to at the proper 
time, and hence do not require further statement here. 

Auditory veetigo is named after its discoverer — Meniere's Dis- 
ease. It has long been known that puncture of the auditory nerve in 
rabbits is followed by rotary movements of the animal. An inflammation 
of the middle ear will often excite convulsions in children. Injecting 
water in the ear will induce vertigo. Meniere described, in 1861, a sud- 
den, excessive vertigo, produced by an hoemorrhagic extravasation or 
some form of exudation into the semicircular canals of the internal ear. 
This is the true Meniere's disease, but vertigo is associated with other 
aural lesions. Thus, it may occur in the course of an otorrhoea, accom- 
panied by noises, beating, singing, and other troubles of the ear. Again, 
without any known disease of the ear, the patient may be disturbed by 
temporary attacks of vertigo, occurring from time to time, until at last 
it becomes a permanent condition. In still other cases an individual 
in full health, apparently, is suddenly seized with a formidable attack 
of apoplectiform vertigo. Many of the cases of temporary or habitual 
vertigo, and of apoplectiform attacks which appear to be independent, 
in reality coexist with disorders of the ear which pass unnoticed. At 
the outset Meniere's vertigo manifests itself in short, sudden attacks, 
separated, by long intervals free from disturbance. If the malady is 
aggravated, the attacks approximate, and finally become constant but 
diversified by paroxysmal exacerbations. In the worst cases the vic- 
tims are compelled to remain in a horizontal position, which moderates 
the distress. But even then they are in an unstable condition, and 
must preserve a most quiet attitude, with closed eyes, if they would 
avoid seizures. The forms taken by the vertiginous sensations are 
various ; sometimes it is a see-saw, a gyratory motion, right or left ; 
sometimes a vertical whirl, a sensation of rising and falling, like the 



VERTIGO. 



627 



swell of the ocean, etc. It is not surprising that persons so affected, 
for months or years, experience changes in character — become morose, 
irritable, suspicio::s. 

In other cases the vertigo, although habitual, is less severe, and 
those affected learn that severe seizures may be avoided by keeping a 
position of fixed attention, and rigidity of the head and members, some- 
what inclined against the direction to which the vertigo carries them. 

The permanent vertiginous sensations are often accompanied by 
various subjective noises in the ears. They assume every kind of 
tone — whistling, singing, beating, roaring, noise of escaping steam, etc. 

Besides the subjective sensation of falling, in certain cases a sud- 
den access of vertigo destroys the voluntary control, and the individ- 
ual is precipitated to the floor. In a portion of these the sensation 
experienced is that of rapid rotation, but a fall may be prevented if 
some support can be seized in time. In others, an irresistible propul- 
sion forward precipitates them on one side or the other, or they fall as 
if struck a violent blow on the nucha, and sometimes with sufficient 
force to be injured in coming down. The fall is forward, rarely back- 
ward, and obliquely to one or the other side, sometimes to the side of 
the affected ear, sometimes to the other side. This lateral propulsion, 
Gowers holds, is diagnostic of Meniere's vertigo. At the moment of 
the attack, the patient, although deprived of voluntary control, does 
not lose consciousness. Nausea and vomiting occur in many cases at 
the end of the seizure ; in others, only nausea is experienced. Some 
glairy mucus and bilious matters are brought up by vomiting, and but 
little food, as a rule. 

Xot all cases of Meniere's disease become habitual and constant. 
In many cases the attacks are isolated, and separated by long intervals 
of entire freedom from the sensations. The attacks may present the 
most violent and characteristic features, or may be mild. The vertigo, 
the gyratory movements, and the vomiting, may take a predominant 
position, but they do not constitute a special form of the disease. Two 
distinct forms may be recognized : one, consisting of a constant state 
of vertigo, diversified by paroxysms ; the other, made up of isolated 
seizures, separated by periods of good health. 

There is no constant anatomical lesion associated with auditory 
vertigo. In many simple cases a sero-sanguineous exudation has been 
found in the semicircular canals ; in other cases there have existed 
complicated lesions, resulting from traumatism. Various lesions of 
the internal ear have been associated with labyrinthine vertigo, such 
as catarrh of the drum and of the mastoid cells. Probably any trou- 
ble of the ear, external or internal, may produce the phenomena of 
Meniere's disease, by modifying the pressure on the terminals of the 
auditory nerve. These phenomena may also be caused by a neuritis 
or perineuritis of the auditory nerve, and have been associated with 



628 



DISEASES OF THE NERVOUS SYSTEM. 



facial paralysis, or other disorders of the facial or chorda tympani. 
When bulbar lesions produce vertigo, there are neuralgic pains in the 
distribution of the fifth nerve, and the same anatomical relationship 
explains the nausea and vomiting, the nucleus of the fifth nerve and of 
the pneumogastric having close connections. 

Stomachal Vertigo is much more frequent and more important, 
therefore, than Meniere's disease. There can be little doubt that it is fre- 
quently mistaken for cerebral disease. It is a misleading error to sup- 
pose that stomachal vertigo is always associated with pronounced stom- 
achal disorder. There are cases in which the disturbance of the intra- 
cranial circulation — the vertiginous sensations — constitute the only ap- 
parent evidence of stomachal disturbance. In such cases the symptoms 
always come on during the stomach or intestinal digestion. In other 
instances there are felt, after eating, a sense of fullness and repletion 
of the stomach, and hebetude of mind. Again, the attacks of vertigo 
are experienced by some persons after eating an article of food especially 
indigestible, and are infrequent. Usually the cerebral symptoms occur 
in the course of well-marked and long-standing stomach and intestinal 
disease. Always after eating heartily there are heaviness and oppres- 
sion, acidity and pyrosis, and frequent eructations occur ; the abdo- 
men some hours after meals is distended with flatus, and constipation 
is the rule. These subjects are usually of full habit, and tend to obe- 
sity, have acid urine loaded with urates, and are rather sluggish, phys- 
ically, although active in their mental habits. Eating habitually 
more than is needed, and leading sedentary lives, unoxidized products 
accumulate in the blood, and uric acid and urates are largely present 
in the urine. Much flatus in the intestine is coincident with the ver- 
tiginous attacks in some subjects. 

Stomachal vertigo may occur under opposite states of the intra- 
cranial circulation ; under anaemia or hypersemia, the latter more fre- 
quently. The evidences of hyperiemia are a rather flushed face, injec- 
tion of the conjunctiva, rather full retinal vessels, and occasional epis- 
taxis. The anaemic subjects are pale, the sclerotics pearly white, and 
the retinal vessels small. The mechanism of the vertigo is complex. 
There are two factors : one consists in the toxic effect of the imper- 
fectly oxidized materials which accumulate in the blood ; the other is 
reflex. An impression made on the end organs of the pneumogastric 
in the stomach is reflected over the sympathetic ganglia or over the 
auditory, including its terminals in the semicircular canals. The 
attacks of vertigo occur in two forms : acute and severe, chronic and 
light. 

The acute and severe attacks occur during the digestion of a full 
meal, or of some especially indigestible material which lingers in the 
stomach. Suddenly there is felt an odd sensation in the scalp, a 
creeping coldness, a sense of constriction, surrounding objects appear 



VERTIGO. 



629 



to go round and round with all the varied movements of the kaleido- 
scope, the individual reels and seizes some object or person for sup- 
port, he has a seasick feeling, more or less intense, and may vomit ; 
his face is pale, pulse feeble, and his vision is blurred. If vomiting 
occur and the stomach is entirely emptied, the symptoms subside. If 
there is nausea, merely, the sick feeling will presently subside and with 
it the vertigo, to return, it may be, in a few minutes, and be repeated 
several times, until the digestion is completed. In other cases the 
nausea persists until some intestinal uneasiness, followed by a copious 
evacuation, occurs. The consciousness is not usually lost in such 
attacks, but the mind is dazed ; in some cases there are hallucinations 
and illusions during the period of vertigo. The depressing effect on 
the vaso-motor system is exhibited, not only in the feeble circulation 
and the sudden pallor, but the surface is bedewed with a cold sweat, or 
sweating is limited to one side of the head or of the body, or to one 
extremity. These acute attacks are doubtless entirely reflex. 

The chronic form of stomachal vertigo is manifested by nearly 
constant headache, noises in the ears, and vertigo, which is daily in 
occurrence, or nearly so. In the most typical cases, a feeling of uncer- 
tainty and unsteadiness comes on after breakfast and increases until 
actual vertigo develops, reaching its maximum some time after dinner. 
At no time is there a degree of unsteadiness requiring support, but a 
feeling of reeling and dizziness, making an effort necessary to preserve 
the vertical position. Not all cases are nearly constant or daily. 
There may be intervals of entire exemption, caused by greater care in 
the selection of food, and by more perfect digestion. Although the 
vertigo may be only occasional, these subjects suffer from headache, 
uneasiness after food, acidity, and flatulence nearly constantly. There 
are a few cases in which, with severe vertigo, no trouble with the 
stomach appears to exist, but on close examination it will be found 
that digestion labors, and that there is a sense of opi^ression at the 
epigastrium. 

The form assumed by the vertigo varies. It may be a sudden 
feeling of emptiness of the head, an apparent sudden deprivation of 
thought, volition, and consciousness. Sometimes there is a mist be- 
fore the eyes, surrounding objects are blurred, the mind is confused, 
and the body reels. In other cases, the individual attacked feels firm, 
but all surrounding objects are whirling around him and around each 
other in inextricable gyrations. By closing the eyes and keeping per- 
fectly quiet, the equilibrium may be maintained, but in some cases 
this stratagem only induces the sensation of rising and falling, of float- 
ing away, etc. When the attacks occur in bed or on the lounge, these 
objects whirl around, or float away, or rise and fall as on the ocean- 
swell. Various hallucinations of sight and illusions occur, but con- 
sciousness is not lost, and delusions are not produced. 



630 



DISEASES OF THE NERVOFS SYSTEM. 



While fhe attacks of vertigo, occurring during the course of the 
chronic form of the malady, are largely reflex, there is another factor 
of considerable pathogenetic importance. Imperfect digestion, espe- 
cially the intestinal, lessened oxidation because of an excess of material 
to be acted on, or diminished supply of oxygen, and sluggish elimina- 
tion, are concerned in the production of a morbid state of the blood, of 
special importance in this connection. The urine is acid in reaction, 
highly pigmented, and heavily loaded with urates and uric acid. The 
most highly specialized tissue will be the first to be acted on by such 
materials in the blood; hence the injury done to the brain and mani- 
fested in the headache, torpor of mind, etc., which are such prominent 
features in these cases of stomachal vertigo. 

Cardiac Vertigo is a condition of anaemia of the brain, and is close- 
ly allied to fainting. The subjects of this malady are rarely free from 
vertiginous sensations on assuming the erect posture, and may be 
violently attacked on making any considerable exertion. They have 
a swimming sensation in the head, darkness falls on the eyes, and they 
become chilly and weak. Cardiac vertigo is associated with fatty 
heart and dilatation of tlie right cavities, conditions already de- 
scribed. 

Cerebral Vertig3 has received attention in connection with the sev- 
eral maladies of which vertigo is a symptom. It occurs as a symptom 
in cerebral anaemia and cerebral congestion ; in cerebro-spinal menin- 
gitis, in which it is very pronounced in the stage of excitation ; in 
tumor of the brain ; in abscess of the brain ; in cerebral haemorrhage, 
as a prodrome ; in sclerosis of the brain ; in chronic endarteritis, with 
thrombosis especially ; in epilepsy, chorea, and hypochondriasis ; in 
chronic alcoholism, and chronic plumbic, paludal, and other forms of 
poisoning, etc. 

Course, Duration, and Termination.— The conditions producing 
vertigo are so various that no uniform course can be laid down. 
Meniere's vertigo is usually incurable, as dependent on lesions that are 
not remediable. In some cases there is a gradual development of con- 
tinuous vertigo from lesions of the ear, and so severe does it become 
that the victim is unable to pursue any occupation — to sit up, even. In 
other cases the attacks are paroxysmal, and occur in the course of 
chronic affections of the ear. The genuine Meniere's disease is a mal- 
ady characterized by a sudden attack of vertigo, with nausea and vom- 
iting so severe that the patient falls as if from an apoplectic attack. 
There has been no previous disease, and the change in the ear consists 
in an hsemorrhagic or sero-sanguineous extravasation into the semi- 
circular canals. Such cases without any other lesions have, in a few 
instances, terminated fatally. Permanent deafness results, and after- 
ward paroxysmal attacks of vertigo occur, or the vertigo may become 
a permanent condition. The fortunes of vertigo, associated with 



VERTIGO. 



631 



aural lesions, are those of the lesions : if the lesions are curable, ver- 
tigo ceases, but as a rule these cases are not hopeful. 

Treatment. — The treatment of auditory vertigo resolves itself into 
the management of the aural lesions. Charcot * has recently called 
attention to the great value of quinine in full doses (ten to fifteen 
grains) in the treatment of Meniere's disease of that form characterized 
by the hemorrhagic or sero-sanguineous exudation into the semicircu- 
lar canals. Confirmatory experience has been reported by Meniere,f 
and by Fere and Demars.J In 1875, say Fere and Demars, Charcot 
made known in one of his lectures at La Salpetriere, the results of a 
new treatment which he had been using some months. He presented 
to the class in attendance a patient, who had many years been confined 
to bed with a vertigo nearly permanent, diversified by extremely 
severe paroxysms. She had subjective noises in the ear, which, joined 
to a purulent discharge from the external auditory foramen, left no 
room for doubt as to the origin of the disease. Charcot conceived the 
idea of modifying the ear-noises by the administration of large doses 
of quinine, which he gave during two months in doses of eight to 
fifteen grains a day. The roaring in the ears was, after a time, re- 
placed by the noise produced by quinine ; the vertigo diminished nota- 
bly, and in two and a half months the patient was able to walk with 
the aid of a cane. Fere and Demars find that, when from eight to 
fourteen grains of quinine are given daily to the patients with auditory 
vertigo, the symptoms of the disease are notably increased. If, after 
eight to ten days' administration, the quinine is suspended, the bruit 
and the vertigo are then found to be much less than before the use of 
the remedy was begun. If the treatment is resumed again, a new ex- 
aggeration of the symptoms occurs, but usually much less than on the 
first trial, and, when again suspended, the improvement is found to be 
still greater. Excellent results have thus been produced. The au- 
thor, from experience in one case only, is able to confirm the report 
as to the exceptional value of quinine in auditory vertigo. 

In the treatment of stomachal vertigo, careful regulation of the 
diet is necessary. It is often extremely serviceable to begin the treat- 
ment by an exclusive milk-diet, and then to reconstruct the dietary, 
according to the condition of the individual subject. Arsenic — one 
or two drops of Fowler's solution, three times a day — is the best 
remedy. TVhen the appetite is poor and the general state feeble, tinct- 
ure of nux vomica is an efiicient remedy. When there is much nau- 
sea, carbolic acid, with or without bismuth, is very serviceable. When 
there is gastro-duodenal catarrh, phosphate of soda is useful in a high 
degree. If the urine is loaded with uric acid and the urates, nitric 

* "Progres Medical," 1875, p. ISZ. 

f " Quelques considerations sur la maladie de Meniere," etc. 
X " Eevue de Medecine," October 10, ISSl, p. 796, ei seq. 



632 



DISEASES OF THE NERVOUS SYSTEM. 



acid or the potash altalles, as tlie case may be, will prove to be very 
beneficial. Each case must be studied by and of itself. Besides the 
merely medicinal and dietetic treatment, much good is accomplished 
by regulated active exercise in the open air. 



DISEASES OF THE MEDULLA OBLONGATA. 



HiEMORRHAGE. 

Pathogeny. — It is a rare event to have haemorrhage occur in the 
medulla or pons, but cases have been reported. The conditions caus- 
ing the haemorrhage are doubtless very much the same as those of the 
brain, miliary aneurisms and atheroma being the chief factors. The 
larger aneurisms of the basilar artery may by rupture cause a haemor- 
rhage affecting this as well as other organs. The medulla is com- 
pressed by hsemorrhages from above, breaking through on to the floor 
of the fourth ventricle. These conditions are not now under consid- 
eration, the inquiry being restricted to haemorrhage into the pons or 
medulla. The vessel affected in any case is small, the resulting clot 
is small, but there are usually several clots at the same time. They 
vary in size from a pea to an olive, but those examples of haemorrhage 
in which the pons is simultaneously affected, or which occur in the 
pons, are much larger. One case is reported in which the haemorrhage 
filled the whole of the pons, burst through on the left side, and also 
filled the fourth ventricle.* Another, in which the pons and fourth 
ventricle were invaded, and into the right crus cerebri there was also 
an extravasation.f 

Symptoms.— If the haemorrhage is large, vomiting usually occurs, 
consciousness is lost, there is complete muscular resolution, abolition of 
all reflex acts takes place, the breathing is sighing and irregular, be- 
coming rapidly shallower, or is stertorous and noisy, the pupils are apt 
to be irregular, one large and the other minutely contracted, or both 
minutely contracted, death occurring in an hour or two, or in a day or 
two, in a deeply comatose state. There is a fulminant form, in which, 
haemorrhage taking place in the medulla at or about the spasm-center, 
the patient falls with a cry into general convulsions, becomes comatose, 
and dies in a few minutes, or in an hour or two. Not all pursue this 
rapidly fatal course. A small clot may form on one side of the medul- 
la or pons, there occur the usual symptoms of apoplexy, and the patient 

* Dr. T. S. Powse, " Transactions of the Pathological Society," vol. xxvii, p. Y. 
f Dr. J. W. Ogle, ibid., vol. xv, p. 9. 



HEMORRHAGE OF THE MEDULLA OBLONGATA. 



633 



emerges from the condition of unconsciousness, after some hours or 
days, paralyzed as to motion and sensation on the opposite side (hemi- 
plegia), or all of the extremities may be paralyzed more or less fully ; 
or there may be a paraplegia, the arms escaping, but usually both upper 
and lower extremities are affected both as to motility and sensibility. 
There are usually paralyses of the cranial nerves — the third, fourth, 
fifth, the sixth, the seventh, etc. — and there may be paralysis of the 
body, on the opposite side of a unilateral lesion, while the cranial 
nerves are paralyzed on the same side. The breathing, owing to the 
proximity of the respiratory center, is irregular in rhythm, sighing, 
dyspnoeic — often of the Cheyne-Stokes type. The action of the heart 
is not so much disturbed, but the pulse may be exceedingly rapid and 
irregular. Epileptiform convulsions are very usual and important 
from the diagnostic point of view, since Nothnagel's " spasm-center " 
is located in this organ, and hence clonic spasm would a priori be ex- 
pected. Difficulty in swallowing (dysphagia) from paralysis of the 
palatal and pharyngeal muscles, and difficulty of speech from paraly- 
sis of the tongue (ataxic aphasia), and sometimes an obstinate singul- 
tus, are present in those cases emerging from the first coma. Albu- 
men or sugar may be present in the urine. 

Course, Duration, and Termination —As the facts above given suf- 
ficiently indicate, the course of haemorrhage into the pons or medulla 
is rapid. Death may occur in a few minutes, in a few hours, or after 
several days. Very few recover in the damaged way above described. 
If such partial recovery ensue, the usual changes of an atrophic kind 
take place in the motor tract below the site of the haemorrhage. The 
paralyzed muscles, innervated by the cranial nerves, it is probable, 
lose their electro-contractility in a few days. 

Diagnosis. — It is often extremely difficult to distinguish between 
the coma and insensibility of haemorrhage into the pons and the nar- 
cosis induced by opium or alcohol. There is no symptom produced by 
one which may not also accompany the other, but the antecedent his- 
tory, taken with the group of symptoms as a whole, ought to conduct 
to right conclusions. The deviation of the head and eyes to the side of 
the intra-cranial disease, and from the paralyzed side, is a symptom of 
cerebral haemorrhage, and not of opium or alcohol poisoning. Con- 
vulsions are uncommon in opium and alcohol poisoning, very common 
in haemorrhage of the medulla. The pupils are often contracted in 
haemorrhage, but never so minutely as in opium-poisoning. During 
the period of unconsciousness it may not be possible to diagnosticate 
between cerebral haemorrhage and haemorrhage of the pons and me- 
dulla, but the more frequent occurrence of convulsions, the vomiting, 
and the irregularity of respiration, may afford indications. Afterward 
the character of the paralysis, the manner in which the cranial nerves 
are affected, the paralysis of the palate, and difficulty of deglutition^ 



634 



DISEASES OF THE NERVOUS SYSTEM. 



the singultus, and the urinary derangements, serve for a ready and 
definite decision. 

Treatment. — The management of haemorrhage into the medulla or 
pons is the same as for cerebral haemorrhage, which has been fully 
discussed. 

OCCLUSION OF THE VESSELS OF THE MEDULLA AND PONS 

VAROLH. 

Pathogeny and Symptoms. — The vertebrals and the basilar are the 
arteries affected. 1'he mode of occlusion is by thrombosis and em- 
bolism, and the pathological results are such as have been described. 
The immediate effect of occlusion of the vertebrals is a sudden and 
intense anaemia, with or without loss of consciousness. There are pa- 
ralysis of the tongue, palate, pharyngeal and laryngeal muscles, and 
paresis of the facial. Sometimes the ocular muscles, innervated by the 
third, and the masseters are also paralyzed, and usually there are great 
irregularities in the respiratory and cardiac movements. Paralysis of 
the four extremities, more frequently hemiplegia, as the left vertebral 
is the one ordinarily closed, results, and there may be, although not the 
rule, lessened sensation in the same parts. Death may ensue at once ; 
the affected area, receiving no blood, ceases to functionate. In other 
cases, the first shock of the accident passes off, the paretic extremities 
contract and become rigid, and may remain in this state for many 
years. The symptoms produced by obstruction of the basilar are 
bilateral, and, as the glosso-pharyngeal and par vagum are paralyzed, 
there occur at the same time severe laryngeal and respiratory symptoms, 
with intense dyspnoea, and rapid carbonic-acid poisoning, and, if the 
immediate effects are survived, paralysis of the four extremities. The 
treatment of this malady is the same as for the same condition affect- 
ing the cerebral vessels. 

ACUTE INFLAMMATION OF THE MEDULLA— ACUTE BULBAR 

PARALYSIS. 

Pathogeny. — The changes resulting from inflammation of the me- 
dulla oblongata are the same as those of encephalitis : hyperaemia ; 
exudation of serum, with its albumen and fibrin ; migration of white 
corpuscles and diapedesis of the red ; disassociation of the nerve-ele- 
ments ; changes in the neuroglia (multiplication of its cells) — the ulti- 
mate result being a spot of softening. 

Symptoms. — The inflammation makes rapid progress. The onset of 
symptoms is sudden : a violent headache ; intense vertigo ; nausea 
and vomiting ; excessive hiccough ; inability or great difficulty in 
swallowing ; toneless voice, or speaking difficult — and these symptoms 
appear without apoplectic symptoms or convulsions. As the medulla 
contains so many important centers within a narrow area, it is obvious 



BULBAR PARALYSIS. 



635 



that there may be much variety in the symptoms. If the pneumogaS' 
trie nucleus is involved there will be embarrassed breathing, cyanosis, 
carbonic-acid poisoning, and the heart's action will be irregular, rapid, 
and weak. Paralysis usually invades the extremities, and varies much 
in extent : there may be hemiplegia, or all four extremities may be 
weak ; sensation is not much affected. Neither tonic contractions of 
the muscles nor convulsions have been observed. The progress of the 
case is rapid. The difficulty of swallowing increases to absolute inabil- 
ity ; the respiration is exceedingly irregular, and carbonic acid accum- 
ulates so that coma results, death occurring by failure of respiration. 

Diagnosis. — It is probable that many cases diagnosticated hydro- 
phobia were really examples of this disease. The distinction between 
inflammation, thrombosis, and embolism of the medulla, can not at 
present be made with certainty. While they all agree in symptoms 
of derangement of the important centers and nerves belonging to the 
medulla, myelitis of this part is not accompanied by apoplectic symp- 
toms or convulsions, which belong to occlusion of the vessels. 

Treatment. — The treatment is the same as that suggested for en- 
cephalitis. 

CHRONIC INFLAMMATION OF THE MEDULLA— CHRONIC PRO- 
GRESSIVE BULBAR PARALYSIS. 

Definition. — This disease is probably better known by the desig- 
nation given it by Trousseau* — glosso-lahio -laryngeal paralysis. 
This term was intended to express the main points in its symptoma- 
tology. Other names proposed are : progressive muscular paralysis 
of the tongue, soft palate, and lips (Duchennef), and progressive 
atrophic bulbar paralysis (LeydenJ;). Chronic progressive bulbar 
paralysis, the term proposed by Wachsmuth, and adopted by Erb, 
well expresses the seat and nature of the disease. 

Causes. — The origin of the disease is very obscure. It occurs much 
more frequently in men than in women, and is a disease of advanced 
life, rarely occurring before forty. It has been referred to cold, to 
shocks, a blow on the neck, to rheumatism, to tertiary syphilis, to deep 
chagrin (Duchenne). It often coexists with progressive muscular 
atrophy (Friedreich §). 

Pathological Anatomy. — Macroscopic examination may furnish only 
negative results. There may be changes of color and a dullness of 
appearance on section, and the medulla as a whole may appear to be 
shrunken, || or harder or softer than natural, in places, but definite 

* " Clinique Medicale," vol. ii, p. 274. 

f " D'Electrisation localisee," second edition, p. 641. 

X Quoted by Ei b, Ziemssen's " Cyclopaedia," vol. xiii. 

§ " Uebcr, progressive Muskelatrophie," Berlin, 1873, cap. ix, s. 322. 

II Lockhart Clarke, " Medico-Chirurgical Transactions," vol. Ivi, p. 103. 



636 DISEASES OF THE NERVOUS SYSTEM. 



results are obtained only by microscopic examination. While the 
lesions in the medulla are so obscure to the naked eye, the nerves com- 
ing from this organ are changed in the most obvious way, especially 
the hypoglossal and facial. The important alteration, in regard to 
which observers are generally agreed, is an atrophy and degeneration 
of the multipolar ganglion-cells of the anterior cornua. The vessels 
are dilated, leaving vacuoles, there are numerous corpora amylacea, 
the cells (nuclei of hypoglossus, etc.) are crowded with pigment, the 
neuroglia overgrown (hyperplasia). Subsequently the cells disintegrate 
and disappear, whence the marked decrease in size. The nerve-roots 
and the nerve-trunks are also much changed, the nerve-fibers having 
undergone fatty degeneration, the neurilemma sclerosed, and the axis 
cylinder wasted till it is barely visible, and only a mass of connective 
tissue left. The most advanced changes are found in the hypoglossal 
nucleus ; next, the spinal accessory and the par vagum are attacked, 
and the facial and glossopharyngeal are more or less damaged, and, 
according to Clarke, the nucleus of the fifth is invaded to some extent. 
Similar lesions occur in the brain and spinal cord — throughout the 
whole extent of the cord, in a case described by Lockhart Clarke, 
which, however, was accompanied by progressive muscular atrophy. 

Symptoms. — The approach of the disease is very insidious. Head- 
ache felt in the occiput, some giddiness, a feeling of choking in at- 
tempting to swallow, a sudden inability to speak (Cheadle), are the 
symptoms first observed. The voice is not lost, but it has a nasal tone 
from the paralysis of the palate, and there is great indistinctness in 
speech because of the loss of power in the tongue and lips, the labial 
consonants not being pronounced. The tongue can not be protruded, 
and it wastes, becoming soon distinctly smaller. The food collects 
about the teeth and the cheek, so that the fingers are needed to dis- 
lodge it. The saliva dribbles from the mouth, the lips hanging limp 
and immovable. The taste is much less distinct or entirely wanting. 
It is a matter of great difficulty for the patient to get the alimentary 
bolus back into the pharynx. The efforts at swallowing excite cough- 
ing and suffocative attacks, and liquids are forced back through the 
nose. The palate and pharynx are so little sensitive that no reflex 
movements are caused by irritating them. The soft palate hangs limp 
and motionless in the fauces. When the disease reaches this point the 
appearance of the patient is eminently characteristic : the paralyzed 
lips and muscles of the face below the eye, their fibrillary trembling, 
and their motionless state in laughing, the flow of the saliva, the fat- 
uous expression, the nasal speech, the inability to sound the labials, 
the choking in swallowing, the return of liquids through the nose, 
form a striking picture which no one can fail to comprehend. It is 
the sad fate of these patients to preserve their mental faculties, except 
that they become somewhat more emotional than formerly, and to con' 



BULBAR PARALYSIS. 



637 



tinue conscious of their condition. The disease is truly progressive — 
the symptoms already described grow worse in every way — speech 
becomes less and less intelligible, swallowing more and more embar- 
rassing and difficult, and the saliva increases in viscidity and quantity, 
the patient requiring a handkerchief constantly to absorb it. Other 
and more formidable symptoms now come on. The extension of the 
disease to the pneumogastric nucleus causes a paralysis of the muscles 
of the larynx, the voice is lost after preliminary weakness and huski- 
ness, the respiratory muscles get weak and the lungs can not be ex- 
panded, and presently there are experienced oppression, heaviness of 
the chest, and constant dyspnoea, with paroxysms of a suffocative 
character, excited by the presence of mucus in the throat, by attempts 
of sneezing, coughing, or swallowing, or by the lodgment of some 
particle of food in the larynx. At the same time the action of the 
heart becomes irregular and weak, and attacks of praecordial oppres- 
sion vrith a sense of impending dissolution occur. The condition of 
the patient is now truly pitiable. The mind is clear. The impossibility 
of swallowing leads to a rapid failure of strength, and, the digestive 
organs remaining unimpaired, an intolerable sense of hunger is felt. 
The termination may now be in a sudden failure of the heart, in an 
attack of pneumonia from lodgment of a foreign body, or by the slower 
process of starvation. The sensibility is unimpaired. The faradic con- 
tractility is at first diminished, but the muscles soon present the phe- 
nomena entitled by Erb the " reaction of degeneration." If the mus- 
cles are far advanced in atrophy, the electro-contractility may be lost. 
The disease in the medulla is often associated with the same degenera- 
tion in the spinal cord, when will be exhibited the phenomena of pro- 
gressive muscular atrophy. Paralyses of muscles of the trunk and 
extremities, with contractions and without atrophy, have been ob- 
served, but these are probably complications. 

Course, Duration, and Termination. — The course of the disease is 
progressive ; from small beginnings it grows into a formidable mal- 
ady. Sometimes a stay in the progress has been noted, but only for 
a brief period, the course being resumed with the former intensity. 
The termination is fatal in from one to five years, in the mode above 
mentioned. An intercurrent malady may fortunately take life earlier ; 
pneumonia is the most usual. The frequent complication of progres- 
sive muscular atrophy, the identity of the muscular condition, and of 
the morbid process in the spinal cord, have led to the view, now gener- 
ally accepted, that the diseases are the same, though differing as to the 
locality in the spinal cord affected. 

Diagnosis. — Diseases of the bulb can hardly be confounded with 
those of other localities, because of the peculiar functional disturb- 
ances which indicate at once the seat of the mischief. Differentia- 
tion is to be made between progressive bulbar paralysis and occlusion 



638 



DISEASES OF TEE NERVOUS SYSTEM. 



of the vessels, acute inflammation, and tumor. Occlusion of the ves- 
sels and inflammation occur suddenly with very severe symptoms, 
often apoplectic, and terminate in a few days. Such is not the 
behavior of progressive bulbar paralysis. Tumor of the medulla and 
pons comes on slowly : there are, at first, symptoms of irritation, 
followed by depression ; in progressive paralysis, the onset is slow and 
obscure, but there are no symptoms of irritation, those of depression 
occurring at once. In the case of tumor, pressure on the cavernous 
sinus is exhibited in swelling of the retinal veins and " choked disks," 
in pufliness of the eyelids and distention of the facial vein — symptoms 
which do not oecur in bulbar paralysis. 

Treatment. — Cheadle * reports a cure by the free administration of 
iodide of potassium, but this must have been a case of gummata. Io- 
dide of potassium has never arrested the progress of, much less cured, 
a genuine case. Galvanism is the most promising remedy. Stabile 
applications, the electrodes on the mastoid processes, and in the oppo- 
site direction, galvanization of the sympathetic, and applications to 
the lips, tongue, and fauces, should be persistently used. The current 
should have suflicient tension to cause slight giddiness and faint flashes 
of light. The seances should be short but daily, and, if suspended oc- 
casionally, can be kept up for the necessary period. Hydrotherapy is, 
next to electricity, the most useful remedy. A wet pack can be worn 
about the neck every night, and a hot douche may be directed to the 
nucha for five minutes daily, but, better, a sponge dipped in hot water 
and kept in contact with the back of the neck for a few minutes. 
The good effects of the water applications are increased by the daily 
use of a mustard-plaster, in contact long enough to induce a little 
redness and nothing more. The internal medicines have not effected 
any improvement in the cases thus far treated. As, under analogous 
conditions, the chloride of gold and sodium has been of great service, 
it should be given a fair trial. Bichloride of mercury acts similarly. 
The utility of these agents probably consists in their power to check 
the overproduction of connective tissue. As lead and other metals, 
slowly introduced into the system, will produce analogous symptoms, 
and as syphilis has the same effect, it is good practice in every case of 
progressive bulbar paralysis to give iodide of potassium, freely at first 
— its subsequent administration being governed by the results of the 
first trial. From the beginning the utmost attention should be given 
to the diet, so as to postpone the period of decline. Soft solids are more 
easily swallowed, when the palate is paralyzed, than liquids. Rectal 
alimentation should be resorted to when the difficulty of swallowing 
becomes great. The injection of defibrinated blood may be em- 
ployed with advantage. 



* "St. George's Hospital Reports," vol. v, p. 123. 



HYPER.EMIA OF THE SPINAL CORD. 



639 



DISEASES OE THE SPHSTAL MEXINGES AND 

CORD. 



HYPER-EIMIA. 

Definition. — As the vascular supply to the meninges and cord is the 
same, and as hypersemia occurs, necessarily in both simultaneously, 
the term hypercemia must be understood to include the contents of 
the spinal canal. There maybe an active^ or arterial hypersemia ; and 
passive, or venous hyperemia. 

Causes. — Hyperaemia is the first stage in the inflammatory affec- 
tions, and is a notable element in variola, typhoid, and intermittent 
fever. It is caused by over-stimulation of the cord in the performance 
of its functions : for example, protracted standing or walking, excesses 
in coitus, etc. Certain spinal poisons cause hyperaemia, as strychnia, 
picrotoxine, amyl nitrite, and alcoholic excess. The arrest of such 
an habitual discharge as from bleeding piles, the menses, etc., diverts 
an excessive quantity of blood to the cord. Probably the most fre- 
quent cause is exposure of the body while in a heated and perspiring 
state to cold and dampness. Congestion is produced by traumatism, 
concussion, etc. Workmen engaged at labor in compressed air suffer 
from hyperaemia, due to the solution and setting free of nitrogen in 
the blood of the spinal canal, as Bert has shown. Venous or passive 
hyperaemia is caused by obstructive disease of the heart and lungs, by 
cirrhosis of the liver, and by tumors of the abdomen. 

Pathological Anatomy. — In active hyperaemia, vessels come into 
view that are invisible in health, and those of larger size are enlarged, 
giving to the meninges and cord a distinctly congested appearance. 
On section, there are more bloody points than in health ; and numerous 
points of extravasation, due to the rupture of capillary vessels, are to 
be seen. The spinal fluid is increased in amount, and is more or less 
reddish from the admixture of blood. Passive congestion is much 
more distinct, owing to the large size and numerous anastomoses of the 
vessels, which are greatly distended, more or less tortuous, and cause 
a bluish discoloration by the increase in size of the numerous small 
veins. Ecchymoses may also form in passive congestion, and the spi- 
nal fluid is somewhat increased in quantity. 

Symptoms. — The symptoms are of two kinds ; those of irritation 
and those of depression. The onset is sudden in the active form, some- 
what more slow in the passive form. Pain in the back, in the dorsal or 
lumbar region, or both, radiates downward through hips and thighs, and 
is increased by movements and by percussion of the skin. The pain 



640 



DISEASES OF THE NERVOUS SYSTEM. 



is rather dull and heavy than acute. Pains are felt in the lower limbs, 
often of an acute character, and with the pain an unpleasant tingling. 
The skin of the lower limbs is abnormally sensitive, and the reflex ex- 
citability of the cord is somewhat augmented. A slight and usually 
transient sense of constriction of the abdomen is felt, and the abdomi- 
nal muscles and those of the extremities are abnormally tense and 
rigid. There is also increased tenderness of the muscles to pressure, 
and they feel sore and ache a good deal, even when at rest. The elec- 
tro-contractility is more prompt than in health. These symptoms of 
irritation occur to both forms of congestion, but they are more acute 
in the active form. The symptoms of depression immediately succeed 
those of excitation. Sensation is diminished ; the lower limbs feel be- 
numbed and heavy, and the movements are weak. 

Course, Duration, and Termination. — The symptoms of irritation 
exist in the active form but a few hours, when the stage of depression 
comes on, the two groups of symptoms intermingling. The whole 
duration of the active form may be a few hours to two or three days. 
The cause continuing in operation, the symptoms will continue ; but 
congestion can not long exist in the active form without setting up 
myelitis. The stage of depression coincides with the escape of fluid 
from the vessels and the occurrence of ecchymoses. Then the cord 
and the nerve-trunks being impinged on, they are functionally de- 
pressed. The termination is in recovery, if the cause is removed, or in 
myelitis. The onset of the passive form and the development of its 
symptoms are gradual ; the symptoms are not so pronounced as are 
those of the active form, and the duration is only limited by that of 
the cause producing it. With various fluctuation the passive form 
may last an indefinite period. 

Diagnosis. — Hyperaemia is distinguished from the more severe 
affections of the cord by the mildness and transitory character of the 
symptoms. From myelitis it is differentiated by the absence of fever, 
severe pains, contractions, paralyses, bed-sores ; from meningitis, by 
fever, the severe symptoms of excitation and of depression ; from 
spinal haemorrhage, by the suddenness of the latter, and the occur- 
rence of depression without symptoms of excitation ; from anaemia, by 
the symptoms of general and local depression characteristic of the 
latter. 

Treatment. — Lying on the back should be avoided. Cups or 
leeches to the spine, if the patient is plethoric, should be applied. If 
the attack has succeeded to sudden arrest of the perspiration, pilo- 
carpine should be used to reexcite the sweat. If the congestion is 
active, the spinal ice-bag may be applied. The blood-pressure should 
be reduced by an active purgative. A descending stabile galvanic 
current should be used once daily if the symptoms persist. A hot 
douche to the spine, every four hours, the author has found remark- 



SPINAL HEMORRHAGE. 



641 



ably beneficial. The internal remedies most useful are, for the active 
form, tincture of aconite-root (two drops every two hours), and infu- 
sion of digitalis (a half -ounce every four hours), unless the symptoms 
of depression increase. In the active form, the author has had excel- 
lent results from the fluid extract of gelsemium (five drops every four 
hours); in the passive form, digitalis and ergot (j — ij 3 fluid extract 
of ergot every four hours) are the most efficient means. In all cases 
the cause must, if possible, be removed. 

SPINAL MENINGEAL HEMORRHAGE. 

Pathogeny. — Injuries and diseases of the vertebrae, penetrating 
wounds, rupture of a vessel from strong muscular effort, as in convul- 
sions, tetanus, lifting a heavy weight, and the spontaneous bleeding 
occurring in hsemorrhagic and infectious diseases, as hiemophilia, scurvy, 
purpura, variola, typhoid, etc., are regarded as the causes. The most 
frequent position of the haemorrhage is in the extra-meningeal con- 
nective tissue. It may form a clot entirely enveloping the dura, or 
occur at isolated spots, or extend over a part of the membrane. The 
dura itself may contain numerous ecchymoses. The coagulum may 
also coat the nerve-trunks up to their point of emergence. In the 
subarachnoid space there may be a quantity of blood, partly fluid 
and partly coagulated, usually quite widely distributed. In the 
meshes of the pia mater, or rather in the subarachnoid cellular tissue, 
there are layers of dark blood, partly fluid, surrounding the cord, and 
extending longitudinally the distance of two or three vertebrae. The 
cord will be compressed if the haemorrhage is large, the part next the 
blood stained red and softened by imbibition. If the nerve-roots are 
long in contact with blood-clot, they will become stained and soft- 
ened. The spinal fluid will be red, and contain particles of clot float- 
ing in it. Hyperplasia of the connective tissue, adhesions between 
the membranes, and extensive pigment deposits, are the results of the 
final changes wrought by haemorrhage. Spinal haemorrhage is not 
unfrequently associated with, or rather results from, cerebral haemor- 
rhage, the blood flowing down into the spinal canal. 

Symptoms. — The usual onset is sudden : intense pains in the back 
and down the limbs are experienced, and the patient falls powerless. 
The other and much less common mode of onset is slower : there are 
pains, strange sensations, headache, and gradual failure of the lower 
limbs. In rare cases cerebral and spinal haemorrhage occur simul- 
taneously ; there are then- sudden loss of consciousness, defects of 
speech, and syncope, in addition to the spinal symptoms. When the 
immediate effects of the haemorrhage subside — the phenomena of 
shock, or apoplexy — then are seen the symptoms of excitation due 
to the presence of the blood. Intense pain in the spine about the site 
43 



642 



DISEASES OF THE NERVOUS SYSTEM. 



of the clot — the whole length, one division, or one or two vertebrae of 
the spine — and radiating along the peripheral tracks of the nerves im- 
pinged on in the canal. In the lower extremities will be felt the 
referred sensations produced by pressure on the cord — tingling, burn- 
ing pain, mixed with numbness. Pressure on the motor nerves pro- 
duces the signs of irritation in the muscles, chiefly contraction, rigidity, 
and cramp ; but there may be trembling, local convulsive movements, 
etc. The muscles of the spine are rigid, and motions of bending or 
turning the body are painful. The symptoms of irritation soon yield 
to those of depression. Numbness, formication, diminished tactile, 
and painful sensations, succeed to the pain and burning ; the muscles 
become weak, and a sense of exhaustion is experienced. Paresis of 
the bladder and rectum is observed when the position of the haem- 
orrhage is low down. In the symptomatology it has thus far been 
assumed that the haemorrhage was not higher than the dorsal region. 
Special symptoms are produced by haemorrhage in the cilio-spinal 
region, and the more if high enough to affect the origin of the phrenic. 
The occiput, the shoulders, and arms, are attacked by pain, spasm, and 
paralysis, the pupil is dilated (irritation), the respiration embarrassed 
(dyspnoea), there is difficulty in swallowing, and the pulse is slow and 
weak. 

Course, Duration, and Termination. — The course of the disease 
varies with the site and extent of the haemorrhage and the compli- 
cations. The first stage (apoplectic) is but a few hours in duration, 
the stage of irritation a few days, and of depression two or three 
weeks. If the haemorrhage be large, cervical, and cranial, death may 
ensue in the apoplectic coma ; if cervical, death may be caused at 
once, or in a day or two, by the disturbance in the respiration and 
heart. Most of the cases in the dorsal and lumbar part get well, the 
clot being gradually absorbed. During the stage of irritation there is 
more or less reactive inflammation, and the products of this help to 
increase the after-depression. The whole course of a case of spinal 
haemorrhage may be completed in one or two months, and health 
restored after a convalescence requiring two months. The prognosis 
will be influenced by the violence of the initial symptoms, by the 
extent of the haemorrhage, the number and severity of the signs of 
irritation, and by the extent of the symptoms of depression. 

Diagnosis. — Spinal haemorrhage is to be differentiated from hyper- 
gemia, spinal meningitis, haemorrhage into the cord, and myelitis. It 
is distinguished from hyperaemia by the suddenness, the violence, and 
the range of the symptoms ; from meningitis and myelitis, by the 
absence of fever, and by the suddenness of onset and more manage- 
able character ; from haemorrhage into the cord, by the fact that in the 
latter there are sudden paralysis without excitation, and extensive 
anaesthesia. 



INFLAMMATION OF THE SPINAL DURA MATER. 



643 



Treatment. — Absolute quiet, the decubitus on the side or face, are 
the first measures. Severe pain must be combated by the hypoder- 
matic injection of morphine, which is furthermore very useful to remove 
restlessness. If the haemorrhage is going on, ergotin should be freely 
used hypodermatically, and general bleeding practiced if the subject 
is plethoric. Bloodletting is improper if the haemorrhage has stopped. 
To promote absorption, the best measures are purgatives, infusion of 
digitalis, and the occasional administration of pilocarpine. Good results 
are obtained by the persistent use of ammonia — ten grains of the car- 
bonate in a tablespoonful of the liquor ammonii acetatis three times a 
day. The products of inflammation (reactive) are best removed by 
the galvanic current to the spine daily, by the hot spinal douche, and 
by the spinal pack worn for a few hours at a time. 

INFLAMMATION OF THE SPINAL DURA MATER— PAOHYMEN» 
INGITIS SPINALIS— PACHYMENINGITIS SPINALIS INTERNA. 

Definition. — Inflammation of the spinal dura mater corresponds to 
the same process of the cerebral dura mater, and the same nomen- 
clature is used. Pachymeningitis spinalis means inflammation of the 
spinal dura mater, and it may be external or internal, the former asso- 
ciated with external diseases and injuries — the latter arising from ordi- 
nary causes. As the latter possesses the greater interest and impor- 
tance, it is alone considered here. There are two forms of pachymenin- 
gitis spinalis interna : the hypertrophic, and the pseudo-membranous. 

Pathogeny and Symptoms. — Exposure to cold and dampness com- 
bined and living in damp habitations are said to be the chief causes of 
the variety known as the hypertrophic. The hsemorrhagic form is 
precisely the same as the haematoma of the cerebral dura mater, and is 
usually found in the subjects of dementia paralytica and of alcoholic 
excess. In the hypertrophic form a great quantity of exudation is 
poured out on the inner surface, which solidifies into a compact con- 
nective tissue, arranged in concentric layers. This ring of indurated 
tissue more or less tightly embraces the cord and sets up a secondary 
myelitis, and, equally compressing the nerve-roots, causes them to un- 
dergo an atrophy, and the muscles to which the nerves are distributed 
also waste in the usual way of muscular atrophy. In the hemor- 
rhagic form a membranous exudation also takes place, developed from 
the sub-epithelial layer (Rindfleisch). This neo-membrane is abundant- 
ly supplied with large, thin-walled vessels, which yielding a large 
haemorrhagic extravasation, in the interstices of the membrane, a cyst 
is thus formed, as has been described in connection with cerebral 
pachymeningitis. The cervical hypertrophic pachymeningitis is one 
of the numerous contributions to knowledge made by Professor Char- 
cot, who has showu that the neck is a favorite seat of the hypertro- 



644 



DISEASES OF THE NERVOUS SYSTEM. 



phic form. He has shown that the first stage is that of irritation, and 
it coincides doubtless with the stage of membranous exudation. This 
first stage is characterized by violent pains in the head, neck, shoul- 
ders, and arms — pains that are continuous, and also subject to exacer- 
bations — and are associated with a painful sense of constriction around 
the upper thorax. This stage of irritation continues two or three 
months, and is succeeded by depression. Then ensue paralysis with 
contraction of the upper limbs, and atrophic degeneration of the mus- 
cles, which lose their electro-contractility as regards the faradic cur- 
rent. Subsequently the lower limbs may become similarly affected, 
but to a much less extent. After remaining stationary for a long 
time, a change for the better may take place and a cure ultimately 
result. 

SPINAL MENlNaiTIS— LEPTOMENINGITIS SPINALIS. 

Definition. — When the term spinal ineningitis is used it is intended 
to express inflammation of the arachnoid and pia mater, for no dis- 
tinction between the two is possible either in respect to the patho- 
logical or clinical standpoint. There may be an acute or chronic 
form. 

Causes. — It is a disease of the male sex, and occurs in youth and 
adult manhood. All depressing influences and the evils of bad hy- 
giene tend to develop it, and it attacks by preference the subjects of 
the scrofulous cachexia. Exposure to cold and dampness, while the 
body is warm and perspiring, is an influential factor. Penetrating 
wounds and injuries and diseases of the vertebrae have a direct effect 
"which is unquestionable. Neighboring diseases affect the spinal me- 
ninges by contiguity ; those of the brain have the most immediate con- 
nection. It occurs also during the course of acute infectious diseases, 
as puerperal fever. 

Pathological Anatomy. — After an intense hyperiemia of the mem- 
branes, punctuated by ecchymoses, much fluid is exuded, and the tissues 
are swollen and infiltrated with serum. A quantity of exudation partly 
purulent and partly fibrinous is poured out ; the spinal fluid becomes 
reddish and muddy from the presence of cells, flakes of fibrin and pus ; 
the membranes are infiltrated with pus-cells, and are coated more or 
less extensively with patches of fibrin, the whole length of the cord 
nearly being covered with exudation. The roots of the spinal nerves 
axe also thickly covered with exudation and bathed with a pathologi- 
cal fluid — the result is, they are swollen, softened, and more or less 
injured by imbibition. The cord itself never escapes entirely ; it may 
be only sodden ; it may be softened, congested, and (Edematous. In 
the chronic form there may be adhesions of the membranes, pigmen- 
tation, large accumulation of fluid, atrophic and sclerotic degeneration 
of the cord, etc. 



SPINAL MENINGITIS. 



645 



Symptoms. — There may or may not be a chill to mark the onset of 
the disease, but a rise of temperature, general malaise, headache, nausea, 
and constipation, with the urine acid and high-colored, indicate the 
beginning of an inflammatory affection. Then occur the local pains, 
which attract attention to the spine — pain, of a severe, deep, bor- 
ing character, in the loins, back, or neck, usually in the dorso-lumbar 
region, rigidity of the spine, a constriction or girdle of severe pain 
around the body, and pains radiating downward into the limbs. The 
motor nerves excited by the exudation cause the muscles to which 
they are distributed to assume a state of spasmodic contraction, limited 
to the lower limbs, to the rectum and bladder (retention of urine and 
constipation), when the lesions do not extend above the last dorsal ; 
extending to the muscles of the trunk and the superior extremities, to 
the respiratory and posterior cervical muscles, if the cervical portion of 
the meninges is invaded. When this portion of the spinal canal is oc- 
cupied by the inflammation, there occur dysphagia, dyspnoea, slowing 
of the pulse, and feebleness of the heart. Striking on the spinal pro- 
cesses does not necessarily awaken pain, but much soreness is felt 
when the spine is bent in the movement of the body. It is important 
to note that the muscular contractions are excited and increased by all 
attempts at movement, whereas irritation of the skin does not have 
this effect — a point of differentiation between meningitis and tetanus 
(Jaccoud). With this condition of the motor functions, there are also 
hyperaesthesia and hyperalgesia of the integument in the area of motor 
derangement. When the respiratory muscles are affected, at this stage 
death occurs early, the pulse becomes very rapid, the dyspnoea increases 
and asphyxia results. Otherwise, the acute symptoms subside, and 
the remission may be the beginning of convalescence. More often this 
diminution of the acuity of the symptoms and the moderation of the 
excitation denote the onset of the paralytic — the stage of depression. 
The paraplegia is not complete ; partial contractions remain in the 
paralyzed members, and more or less hyperaesthesia persists. Consti- 
pation from paresis and urinary retention are replaced by inconti- 
nence, but this is not invariable. Reflex movements are not abolished. 
Anaesthesia will more or less, but not entirely, replace hyperaesthesia. 
The electro-contractility (faradic current) is not impaired in some 
muscles, but is weakened and lost in others. The extensors are more 
often affected by atrophy and loss of electro-contractility (Rosenthal *). 
The cases may now follow two courses : In one the symptoms of paral- 
ysis will invade the respiratory muscles, and death will occur in coma 
(carbonic-acid poisoning), the temperature sometimes rising to an 
extraordinary height. In the other case, the course will be more pro- 
tracted ; there will be periods of apparent improvement, but the paraly- 



* "Klinik der Nervenkrankheiten," Stuttgart, 1875, p. 286. 



646 



DISEASES OF THE NERVOUS SYSTEM. 



sis will extend, bed-sores will form, urine will dribble away, and death 
occur finally by exhaustion. If the disease extend to the medulla, 
there will be produced, besides the disturbances of respiration and 
of the heart which occur when the cervical meninges are inflamed, 
affections of speech, vomiting, ocular derangements, delirium, etc. 
There is no characteristic thermal line ; the fever is high at the outset, 
but the temperature declines during the stage of depression, to rise 
sometimes to an extraordinary height during the death-agony. The 
appetite is lost, the body wastes rapidly, and emaciation, in the cases 
with bed-sores and death by exhaustion, proceeds to a remarkable ex- 
tent. The chronic form of spinal meningitis succeeds to the acute 
cases of moderate severity, or originates spontaneously — the latter 
more frequently. It presents the same form and order of symptoms — 
those of excitation, those of depression. These effects are due to effu- 
sions and membranous exudations in the spinal canal. The membranes 
are thickened, pigmented, and adherent to each other and to the cord. 
The pressure of the contracting sclerotic connective tissue induces 
atrophy of the nerve-roots, and if the posterior roots are impinged on 
degeneration may occur in the posterior columns (Rosenthal). The 
cord itself is ultimately damaged by a parenchymatous myelitis. The 
symptoms of irritation are chiefly expressed in disorders of sensibility, 
muscular rigidity and spasm being partial and fugitive. The pain is 
felt in the lumbar region and through the lower limbs, and has a rheu- 
matismal character. The pain is accompanied by hypersesthesia, which, 
however, is never so considerable as in the acute form. Paraplegia 
develops slowly : at the first there is a strong sense of fatigue, then of 
increasing weakness ; numbness, tingling, and slowly marching plantar 
anaesthesia, come on in the order named. The weakness extends to all 
the muscles of the inferior extremity, and to the rectum and bladder, 
and may ultimately invade the upper extremities, always in its march 
attacking the two sides of the body equally. This form of paraplegia 
is irregular in its progress — now advancing, now receding. 

Course, Duration, and Termination.— The fulminant form termi- 
nates in a few hours or a few days, its course being characterized by 
the extent and diffusion of the symptoms, the early implication of the 
cervical portion, and consequent failure of the lungs and heart. The 
ordinary severe form lasts two or three weeks, and terminates in either 
of two modes : in from one to two weeks by the embarrassment of 
respiration and weakness of the heart, coma developing in consequence 
of carbonic-acid poisoning ; in from two to four weeks, by gradual 
failure, death being due to exhaustion. The severe form may termi- 
nate in recovery. At the end of the excitation period a remission in 
the symptoms occurs, the stage of depression does not develop into 
paraplegia, and convalescence proceeds slowly, the health being rees- 
tablished not until two or three months have elapsed. In the most 



SPINAL MENINGITIS. 



647 



favorable cases a change for the better may take place in the exci- 
tation period in a few days, and convalescence be established, or the 
symptoms be resumed in a milder form, convalescence being then 
established. Not unfrequently some critical evacuation, such as a pro- 
fuse sweat or urinary discharge, an epistaxis, or menstrual or haemor- 
rhoidal discharge, marks the cessation of the morbid process, and a 
rapid recovery then takes place. More frequently the recovery is 
slow, owing to extensive exudations, and there is a long period of 
lameness or paralysis. Again, recovery may ensue with permanent 
disability of a member, or group of muscles. In any case, the prog- 
nosis is serious. 

Diagnosis. — The distinction between tetanus and spinal meningi- 
tis rests on these points : trismus is among the first symptoms of teta- 
nus, and rarely occurs, and then later in spinal meningitis ; risus sar- 
donicus is peculiar to tetanus; the spasms are rhythmical in tetanus, are 
more severe, and are excited by reflex causes — similar spasms do not 
occur in meningitis, are much less severe, and are only excited by 
movements. In tetanus, no oculo-pupillary phenomena, no changes in 
the cranial nerves, no delirium, no fever — all occur in meningitis. The 
history of the case, especially the presence of a wound, will often de- 
cide. From myelitis, meningitis is differentiated by the pain in the 
back, the hyperaesthesia, the muscular rigidity, and on the part of 
myelitis by the early paraplegia and anaesthesia. Rosenthal places 
much stress on the electrical state of the muscles — the electro-contrac- 
tility and sensibility (farad ism) of the nerves are much lessened, or 
disappear entirely in spinal meningitis. From typhoid fever, by the 
thermal line, by the absence of the irritation symptoms, by the diar- 
rhoea, by the stupor — in fact, the least attention ought to decide 
promptly. 

Treatment. — Absolute repose in a darkened room, the decubitus 
lateral or on the face, must be insisted on. Leeches or cups to the 
spine during the period of excitation — the amount of blood drawn 
being dependent on the vigor of the subject. The application of the 
spinal ice-bag may be proper, but caution is necessary. The author 
has a strong conviction that hardly any topical application is to be 
compared with the hot douche to the spine, or, instead, a large sponge 
dipped in hot water and passed frequently over the spine. The most 
efficient internal medicines are opium, aconite, and ergot — two drops of 
the tincture of aconite-root, five to ten drops of the tincture of opium 
(deodorized), and fifteen to thirty minims of the fluid extract of ergot 
every two hours during the stage of excitation. If the pain is very 
severe, the hypodermatic injection of morphine may be necessary at the 
outset. As opium is a remedy of the greatest importance, its effects 
should be steadily maintained during the excitation stage. When the 
symptoms of depression come on, quinine (three grains) and belladonna 



648 DISEASES OF THE NERVOUS SYSTEM. 

extract (one fourth of a grain), every four hours, are the most useful 
remedies. The paralysis of muscles during the period of convalescence 
is best treated by faradization, or galvanism slowly interrupted, if the 
former fails to induce responses. The galvanic current should be ap- 
plied to the spine and to the nerve-trunks. After the acute symptoms 
have subsided, strychnine may be injected into the paralyzed muscles. 
Massage to the paralyzed members or muscular groups is an expedient 
of great utility. During the excitation period, and after cups or leeches 
have been applied, mustard-plasters to produce slight rubefaction are 
highly useful. Twice a day, a mustard-plaster four inches broad should 
be put on from the occiput to the sacrum, and removed as soon as 
slight redness is caused. During the stage of depression, ^ym^-blis- 
ters to the spine are highly serviceable. Great circumspection is ne- 
cessary, since all severe counter-irritation may help to form bed-sores. 
To remove deposits from the spinal canal, especially in the treatment 
of the chronic form of spinal meningitis, and the pachymeningitis in- 
terna of the cervical region, there is no remedy so efficient as the iodide 
of potassium, especially when its actions are aided by the occasional 
administration of pilocarpine. 



ACUTE MYELITIS. 

Forms. — Myelitis implies an inflammation of all the tissues of the 
cord. There are several forms, determined by the seat and range of 
the inflammation. It is sometimes designated diffused myelitis, and 
it may be acute or chronic. It is further distinguished into central 
myelitis, when the inflammation occurs chiefly in the central gray mat- 
ter ; into tra?isverse myelitis^ when all the tissues of the cord at cer- 
tain levels are involved, as, for example, dorso-lumbar, dorsal, and 
cervical transverse myelitis ; into hemilateral, when a longitudinal 
half of the cord is affected, and disseminated, when there are spots of 
inflammation scattered along the cord at various points through its 
whole length. 

Causes. — Myelitis is more common in males than in females ; in 
youth and early manhood than in advanced life. One form occurs in 
childhood. Contusions, blows, fractures of the vertebra, severe and 
prolonged functional activity of the cord, as in protracted standing, 
excesses in coitus, self-abuse, exposure to cold and dampness combined, 
are the most common causes. Inflammation of the cord may be excited 
by neighboring inflammations, transmitted by contiguity : meningitis, 
traumatic inflammation of the dura, and carcinoma, are the representa- 
tives of this group of causes. It is one of the complications of typhus, 
the exanthemata, puerperal fever, and acute rheumatism. The so- 
called reflex paraplegias are often, probably, examples of myelitis. 

Pathological Anatomy. — The first step in the process is hypersemia, 



ACUTE MYELITIS. 



649 



which is usually very intense, the affected area being deeply red. Ex- 
travasations also occur, and hence the tissues may have a reddish-brown 
or chocolate tint. With the hypersemia occur serous transudations, 
so that the inflamed district is moist and juicy, and softened. A change 
in coloration next takes place to yellow, and ultimately to white, the 
nerve-elements are disassociated, become fatty, and finally an emulsioned 
mass remains, of creamy appearance and consistence. The meninges of 
this part of the cord take part in the inflammation, become thickened, 
opaque, and infiltrated with pus-cells, and contract adhesions. Such 
are the macroscopic or naked-eye appearances. On microscopic ex- 
amination the changes consist in dilatation of the capillaries, arteri- 
oles, and veins ; in the migration of the white and diapedesis of the 
red corpuscles ; in fatty and granular infiltration of the walls of the 
vessels ; in the exudation of a colloidal hyaline substance about the 
vessels ; in sw^elling and proliferation of the neuroglia-cells, and a 
hyperplasia of the reticulum ; in the exudation in great numbers of 
granule-cells in the interstices ; in the granular disintegration of the 
nerve-fibers, the axis-cylinders forming ampullary dilatations : and in 
swelling, proliferation and granular atrophy of the ganglion-cells. The 
continued development of these morbid processes results in the almost 
entire disappearance of the proper elements, the remaining mass being 
composed of fat-granules, hypertrophied neuroglia, dilated and thick- 
ened vessels. Cysts are sometimes seen, composed of a dense connec- 
tive-tissue envelope, and a reticulum of the same, containing serum 
and detritus. Without proceeding so far as the complete destruction 
of the nerve-elements (cells and fibers), which is the ultimate step in 
the acute process, a transition to the chronic forms is effected, in which 
there is an hyperplasia of the neuroglia, the spider-cells enlarge and 
increase in number, the vessels undergo thickening, numerous amyla- 
ceous corpuscles or bodies appear, while the nerve-elements atrophy. 
The central gray matter is the chief seat of this disease, but it extends 
so as to involve all parts. It may be most severe in the gray matter ; 
it may have an hgemorrhagic character, and it may consist chiefly in a 
hyperplasia of the neuroglia. 

Symptoms. — The usual course is the onset by a chill, fever, and 
general malaise. Or the spinal symptoms begin without any prelimi- 
nary. There are experienced intense pain in the back, with a band 
of pain and constriction around the body, soreness developed by per- 
cussion of the spine, pains and muscular soreness of the limbs, tingling, 
formication, a feeling of weight and dragging in the rectum and blad- 
der, and priapism. There may be, but not invariably, corresponding 
symptoms of irritation in the motor sphere, such as tremors, spasmodic 
contractions, clonic convulsions partial, even general. But paralytic 
symptoms appear in a few hours, and soon complete paralysis, and dis- 
appearance of the electro-contractility (reactions of degeneration). Pa- 



650 



DISEASES OF THE NERVOUS SYSTEM. 



ralysis of the sensory nerves also takes place in a short time, and sen- 
sation is lost more or less completely in all the affected region up to 
the upper line, often terminating quite abruptly about the middle of 
the body. The analgetic parts may also be the seat of violent pains 
{ancBsthesia dolorosa). Paralysis of the sphincters may follow very 
soon the paralysis of the muscles, but it may be delayed for some 
time, and in other cases it may not occur at all. The condition of 
the reflex function varies greatly. All reflex activity may be abol- 
ished ; it may be diminished ; it may be unchanged ; it may be greatly 
exaggerated — the variations being due to the position and extent of 
the lesion in the cord. Sometimes the paralysis reaches its highest 
at once and is afterward stationary; sometimes it ascends the cord 
and rapidly involves the parts above ; sometimes the extension is 
transversely, all parts of the cord in turn being affected. When the 
inflammation extends horizontally and affects the anterior cornua, the 
paralyzed muscles waste rapidly, and bed-sores form quickly and 
spread widely. These trophic lesions also excite disease of the raucous 
membrane of the genito-urinary tract, the urine becomes alkaline, and 
a violent and destructive pyelonephritis and cystitis are set up, the 
paralyzed limbs become cedematous, and effusion takes place into the 
joints. If the myelitis is of the ascending variety, when the cilio- 
spinal region is reached, pupillary phenomena are observed — en- 
larged pupil, if the sympathetic centers are merely irritated ; con- 
tracted pupil, if these centers are destroyed. When the cervical 
portion of the cord is reached, the muscles of respiration becoming par- 
alyzed — the intercostals and trunk-muscles — breathing can be carried 
on only with the diaphragm, and finally, this muscle being paralyzed, 
there are most intense dyspnoea, rapid filling of the lungs, and death. 
The fever with which many cases are inaugurated pursues no defined 
plan. In some cases fever persists throughout, in many it is parox- 
ysmal, but without regularity, in others it does not appear at all. In 
some instances intense fever precedes death, and is higher than ever 
immediately after death. The pulse is frequent usually, very fre- 
quent and irregular when the cervical portion of the cord is invaded. 
The nutrition in some cases fails rapidly, in others is preserved fairly 
well. There are obstinate constipation and meteorism produced by 
paralysis of the muscular layer of the bowel. 

Course, Duration, and Termination. — There are numerous variations 
in the course of the disease, due to the position and tendency of the 
lesions. If the paralysis is of the ascending variety, the respiratory 
muscles soon become involved, and death takes place in a few days by 
asphyxia. In other cases, the trophic center being invaded, there 
occur extensive bed-sores, intense pyelonephritis and cystitis, changes 
in the joints, and death by exhaustion in three or four weeks, or as 
many months. It occasionally happens that the morbid process is ar- 
rested at a certain stage, and the health is restored ; but, permanent 



ACUTE MYELITIS. 



G51 



damage having been inflicted, permanent deformity remains, such as 
wasted and paralyzed muscles, contractions, and deformities of joints. 
In still other cases, the acute passes into the chronic form of the dis- 
ease. Rarely, complete recovery ensues. When this result takes 
place, a remission occurs at an early period, the paralysis is not com- 
plete, and slow absorption of exudations is effected. The myelitis 
from traumatic causes is usually situated above the dorso-lumbar en- 
largement, and is of the variety known as myelitis transversa. The 
symptoms present are the constricting band around the body, spinal 
pain, paraplegia, anaesthesia, no atrophy of the muscles, paralysis of the 
bladder, and reflex contraction of the muscles more active than normal. 
The electro-contractility of the leg-muscles is preserved. Central mye- 
litis affects the gray matter, including the anterior horn. This form 
begins abruptly, proceeds rapidly, and involves sensation and motion 
and the troj)hic functions. The reflex excitability and the electro- 
contractility (faradism) are quickly extinguished (reactions of degen- 
eration), the muscles waste rapidly, the muscles of respiration are 
quickly paralyzed by extension upward of the disease, and death oc- 
curs early by asphyxia. The hcemorrhagic form differs from the purely 
central myelitis by the still more abrupt appearance of the paralysis. 

Diagnosis. — Myelitis may be readily confounded with meningitis : 
they differ especially in respect to the stage of irritation, which is pro- 
nounced in meningitis, but hardly recognizable in myelitis. In menin- 
gitis, there are rigidity, spasms and contractions of muscles, pain and 
hyperaesthesia ; in myelitis, paralysis appears in a short time, involves 
the rectum and bladder, and anaesthesia follows. The electro-contrac- 
tility is preserved in meningitis, but often lost in myelitis. Haemor- 
rhage in the spinal canal is distinguished by its abruptness, the irrita- 
tive symptoms (absent in myelitis), the slight paralysis and preserva- 
tion of electro-contractility, as against the severe paralysis, wasting 
of muscles, loss of reflex and electric excitability, and trophic disor- 
ders characteristic of myelitis. Haemorrhage into the cord is recog- 
nized by the abruptness of the symptoms, sudden paralysis without 
fever or other constitutional disturbance, the loss of power being 
stationary. 

Treatment. — Absolute rest and the avoidance of all excitement, 
decubitus on the side or face, and careful and nutritious alimentation, 
are the first measures. The frequent application of hot water to the 
spine — preferably the hot douche — is very serviceable ; in some in- 
terval between these applications, a mustard-plaster the length of the 
spine and four inches broad should be put on, and retained no longer 
than beginning rubef action, and repeated twice a day. Internally, 
the best results are obtained from the infusion of digitalis (a table- 
spoonful four times a day), for this remedy is preferable to ergot in 
the acute inflammatory affections of the spine, owing to the peculiar 
arrangement of the spinal veins. Local bloodletting and purgatives 



652 



DISEASES OF THE NERVOUS SYSTEM. 



are useful in plethoric subjects. As the stage of congestion passes 
into the stage of exudation, ammonia (the carbonate) should be given 
freely (five grains every three hours). Any specific infection must 
be regarded in the plan of treatment adopted. As the stage of de- 
pression develops, quinine in small doses, and belladonna extract, may 
be very useful. Scruple to half -drachm doses of quinine may have a 
good effect at the very beginning of the congestion stage. 

CHRONIC MYELITIS. 

Forms. — Under the term chronic myelitis are included various 
changes in the cord, of induration or sclerosis, and gray or gelatini- 
form degeneration, and, less often, of softening. The several forms of 
chronic myelitis, named according to their seat and character, are cen- 
tral^ transverse, progressive, and disseminated myelitis. Each form has 
its distinctive symptomatology, because of the functions of the dif- 
ferent parts of the cord. 

Causes. — The causes of chronic are much the same as those of 
acute myelitis. It may arise from the acute form ; may be due to in- 
juries, concussions, blows on the spine ; may result from sexual excess, 
from exposure to cold and dampness, or from the arrest of some habit- 
ual discharge. The so-called reflex paraplegias are probably nothing 
more than chronic myelitis, arising from reflex disturbances. 

Pathological Anatomy. — The changes are of several kinds. Macro- 
scopically there may be no alteration, or the consistence and color may 
be visibly changed. As to consistence, there may be sclerosis or soft- 
ening, the latter much less frequently, and in color the change is to a 
grayish or yellowish-gray discoloration — an evidence of the existence 
of gray degeneration. The patches of sclerosis may be localized, or 
diffused, or disseminated. The changes may be limited to the central 
gray matter, and especially to that part surrounding the central canal, 
or to the gray matter of the anterior cornu, or to the lateral columns 
or to the posterior columns. Again, the peripheral part of the cord 
may be affected in conjunction with the pia.* The nerve-roots may 
be more or less advanced in the gray or gelatiniform degeneration, the 
nerve-trunks atrophied, and the muscles to which they are distributed 
equally affected by an atrophic degeneration, partly fatty. Various 
trophic changes occur in the joints and mucous membrane of the gen- 
ito-urinary tract, and bed-sores form. The microscopic changes con- 
sist in an hyperplasia of the neuroglia— the fibers increase in number 
and size, and the cells undergo a nuclear proliferation. Various changes 
occur in the nerve-fibers : they may be swollen, disintegrating, fatty ; 
the axis-cylinder equally atrophied or indurated. The ganglion-cells 
are shrunken, pigmented, indurated, lose their processes, and their 

* Vu]pian, " Archives de Physiologie," tome ii, p. 2*79, "Note sur un cas de meningite 
spinal et de sclerose corticalc annulaire de la moclle epiniere." 



CHRONIC MYELITIS. 



653 



nucleus and nucleolus alike disappear. The vessels also undergo im- 
portant changes : the adventitia is indurated, and is the seat of nuclear 
proliferations and formation of fat-cells, and is thickened as well as 
indurated. IN'umerous fat granules and cells and corpora amylacea 
are distributed through the sclerosed patches. 

Symptoms. — The symptoms are at first without much significance. 
Disorders of sensation usually precede the motor disturbances. There 
are pains in the limbs that have the character of and are usually con- 
founded with muscular rheumatism, tingling, mixed with numbness, 
and some burning ; pain in the back, and a sense of constriction around 
the body — the girdle or band feeling ; sometimes the integument over 
the spine is highly sensitive. Motor disturbances next appear. Mus- 
cular fatigue is felt without exercise, and becomes severe when any 
effort, as in walking, is made. The feet and legs feel heavy, and their 
movements are awkward. With the progress of the case, sensory 
depression, after a time, supersedes all the symptoms of excitation. 
Numbness is felt in the fingers in the distribution of the ulnar nerve, 
in the toes, and in the bottoms of the feet, which feel as if a cushion 
were interposed between them and the floor. The various endowments 
of the sensory nerves disappear in turn — first the impression of tick- 
ling, then touch, pressure, temperature, and finally pain (Rosenthal). 
The anaesthetic area is the front part of the thighs, the hips and loins, 
the inferior portion of the body upward to either side of the abdo- 
men. There are parts below the girdle-line in which sensation is only 
lessened, and parts that still retain their normal sensibility. Strange 
aberrations of sensations are observed in the ansesthetic regions — the 
application of heat may cause a sensation of coldness, of cold, a hot or 
burning feeling. Furthermore, an impression made at any spot may 
be referred by the patient to some distant point, or indeed to the 
other side of the body. The rate at which impressions are transmitted 
from the periphery to the centers of consciousness is much lessened in 
this disease owing to the obstacles in the paths of conduction — sec- 
onds even being occupied in the passage of an impression from the 
great-toe to the sensorium. The paresis or paralysis extends from 
below upward, very rarely in the opposite direction. The position of 
the paralysis depends on the part of the cord invaded. If the cervical 
portion, the upper extremities will be the seat of motor and sensory 
disorders, the pupils will be unequal, there will be embarrassment of 
respiration in consequence of paralysis of the intercostals and muscles 
of the chest above, the action of the heart will be rapid and weak, 
there will be suffocative attacks, and difiiculty in swallowing. If the 
dorso-lumbar enlargement be involved, there will be the paralysis of 
the lower limbs (paraplegia), of the bladder and rectum, the electro- 
contractility (reactions of degeneration) and the reflex excitability will 
be both abolished ; but, if above the dorso-lumbar enlargement, the 
reflex and electro-contractility will be rather heightened. The para- 



654: 



DISEASES OF THE NERVOUS SYSTEM. 



lyzed muscles waste and lose their electric reaction — tlie anodal disap- 
pearing before the cathodal reaction. The sexual functions decline 
correspondingly. At first there is priapism, but the erections presently 
cease altogether ; yet nocturnal pollutions occur from time to time until 
absolute impotence results. The urine is at first frequently discharged 
with difficulty ; there may be incontinence and dribbling, or retention 
and a catheter needed. Constipation and meteorism are present, be- 
cause the muscular layer of the bowel is either paretic or paralyzed. 
The general nutrition often continues in a satisfactory state throughout, 
but, in the severe cases and toward the end of most cases, much suffer- 
ing is experienced from the wakefulness, bed-sores, the incontinence of 
urine, and the inflammatory reaction from cystitis and pyelonephritis. 

Course, Duration, and Termination. — The development of the disease 
is slow, whether the chronic succeeds to the acute or originates de novo. 
Its progress is slow, and, although varied by periods of apparent im- 
provement folloAved by exacerbations, its tendency is downward. Nev- 
ertheless, there are in many cases long periods of a perfectly unchang- 
ing state in which the damage done continues, and no change for the 
worse takes place for many years. Even in those cases which seem 
stationary, there should be not too confident hopes of an arrest, since 
relapses may occur. In any case there can be no true recovery ; only 
an arrest of the morbid action, for the damage done is permanent. 
There are various modes of termination : by cystitis, pyelonephritis, 
and bed-sores, by some intercurrent malady, as pneumonia or pleuritis, 
or by the extension upward into the cervical region. 

Diagnosis. — We have first to distinguish the several forms of mye- 
litis, as regards the seat of the lesions and the mode of their progres- 
sion. When the cervical portion of the cord is affected, the symp- 
toms of irritation and depression are seen in the hands and arms, in 
the disturbances of respiration and circulation, in the oculo-pupillary 
phenomena, the lower extremities and the sphincters becoming affected 
subsequently. If the dorsal portion is affected, above the dorso-lum- 
bar enlargement, the respiration will be affected by paralysis of the 
intercostals, the constricting girdle will be high up about the nipples, 
there will be paraplegia and paralysis of the sphincters, but reflex and 
electro-contractility will not be affected, rather heightened than dimin- 
ished. If the lumbar region is affected in addition to the symptoms 
of the dorsal, there will be loss of reflex and electro-contractility and 
usually the trophic disorders. When the disease invades the multipolar 
cells of the anterior horns, it is called poliomyelitis anterior chronica^ 
the paralytic symptoms occur as in the disease of the other parts of 
the cord, but in this region lesions produce trophic changes in the par- 
alyzed parts, rapid wasting of the muscles, changes in the joints, bed- 
sores, cystitis, etc., and loss of reflex and electro-contractility. Chronic 
myelitis is distinguished from haemorrhage into the cord by the sud- 
denness of the onset, and the prompt development of paralysis charac- 



CHRONIC MYELITIS. 



655 



teristic of the latter. From spinal meningitis, by tlie excitation symp- 
toms, and the preservation of the reflexes and the electro-contractility, 
and the presence of febrile excitement, all wanting in chronic myelitis. 

Treatment. — If the disease is recent and advancing, rest takes the 
first rank as a remedial agent. The rest must be as nearly absolute as 
possible, and should be kept up for two to three months to be of any 
service. Erb regards the hydropathic method as the most successful ; 
the local application of cold water by compresses to the spine, removed 
when they get warm ; the " rubbing wet pack," the application re- 
stricted to the back and body, hip-baths, and the half-bath, with 
douches to the spine.* The temperature of the water should not 
exceed 80° Fahr., and should not fall below 55°, and the treatment 
should not be continued too long. If patients do not react v/ell and 
remain chilly, the treatment does no good. The author has had re- 
markably good results from the application of the hot douche in cases 
of myelitis. Next to hydrotherapy, galvanism is the most useful agent. 
The important point, too little understood, is the use of a large volume 
and low tension. From forty to sixty elements of Siemens and Halske 
and large sponge electrodes well moistened are the principal needs. 
The individual applications should be about two to five minutes' dura- 
tion, and should be made daily. The duration of the treatment will 
be influenced by many considerations, by the benefit or injury espe- 
cially. Even if it do good, the current should not be used daily for 
months at a time, but a few days' intermission every month are neces- 
sary. The direction of the current seems a matter of indifference, but 
the author believes, if the blood-supply is to be increased and the nutri- 
tion improved, that the descending current is better. Mtrate of silver 
has been beneficial in many cases. The author has seen good results 
from the chloride of gold and sodium, alone, and in combination with 
minute doses (gV gr.) of corrosive sublimate. Of all the agents for 
the period of depression, the author regards the lactophosphate of 
lime as the most permanently beneficial. It may be given with arsenic 
and contemporaneously with cod-liver oil. The diet must be light and 
easily digested, especially so in those cases undergoing the rest-cure. 
Spirits must be forbidden. One of the most unpleasant complications 
of myelitis — incontinence of urine — may often be relieved by faradiza- 
tion of the bladder, which is best accomplished by introducing a but- 
ton electrode into the rectum, and applying a sponge electrode to the 
hypogastric region. 

POSTERIOR SPINAL SCLEROSIS— PROGRESSIVE LOCOMOTOR 

ATAXIA. 

Definition. — Posterior spinal sclerosis is a form of myelitis, which 
does not extend transversely but longitudinally, and is limited to the 

* See the author's " Materia Medica and Therapeutics," sixth ed., art. " Hydrotherapy." 



656 



DISEASES OF THE NERVOUS SYSTEM. 



posterior columns. The term progressive locomotor ataxia was ap- 
plied by Duchenne to designate the special characteristics of the mal- 
ady. This disease has long been known in Germany under the term 
tabes dorsalis. 

Causes. — Probably the chief cause of posterior spinal sclerosis is 
inherited tendency. Some striking examples of this disease appearing 
in collateral family lines have been reported by Friedreich.* It is some- 
times directly transmitted ; thus, Carre has reported an instance of one 
family, among whom there were eighteen cases in three generations.! 
It is a disease of the most active period of life, occurring from twenty 
to sixty, but the cases are most numerous between thirty-five and fifty. 
It attacks males twice as often as females. Occupations involving ex- 
posure to cold and dampness, to fatigue, and depressing moral emotions, 
favor the development of the disease. It is alleged that railroad- 
engine drivers, stokers, conductors, and brakemen, suffer from this and 
other spinal diseases by reason of the concussion. There are no statis- 
tics or exact observations thus far published on this point. Sexual ex- 
cesses are generally held to be influential in causing this disease, but, 
as an unusual salacity is one of the first manifestations of the changes 
taking place in the cord, there is danger of confounding cause and effect. 
There seems to be no doubt that there is a relation between rheumatism 
and locomotor ataxia. J The author has seen a well-marked case, pro- 
duced in a gilder by his occupation, the symptoms ultimately disap- 
pearing under iodide of potassium. It is probable that the slow absorp- 
tion of the metals used in the arts is often responsible for the 23roduction 
of symptoms similar to those of posterior spinal sclerosis. That the 
syphilitic cachexia stands in an intimate causal relation to this disease 
seems well established by modern researches. By this statement, it is 
not intended to express the notion of an ataxic condition due to syphi- 
loma of the spinal cord, but rather that the disease arises in the poste- 
rior columns in consequence of the development of a peculiar cachexia, 
the product of syphilitic infection and of the remedies used for its cure. 

Pathological Anatomy. — The meninges may be unaffected, but in a 
majority of cases the pia mater presents the appearances of increased 
vascularity along the region of the posterior columns. The form, 
color, and consistence of the cord are altered. The change consists in 
an atrophy of the posterior columns, and hence there is a shortening 
of the antero-posterior diameter ; in a gray, semi-transparent, rather 
vitreous, amber, rose or reddish-yellow color, which contrast strongly 
with the adjacent whitish nervous matter, and in an increase of the 
consistence of the affected area, although it may also be softer than 
normal. The extent of the degeneration varies in different cases, 

* " Ueber Ataxic mit besonderer Beriicksichtigung der hereditaren Formen," von Pro- 
fessor Dr. N. Friedreich in Heidelberg, Virchow's " Archiv," Band Ixviii und Ixx. 
\ Erb, op. cit. 

X Topinard, ''De I'Ataxie Locomotrice," etc., Paris, 1864, p. 363, 



POSTERIOR SPINAL SCLEROSIS. 



657 



but in general it occupies the parts between the posterior roots, and is 
most considerable in the dorsal and upper lumbar portion of the cord, 
but it may extend from the filum terminale to the calamus scriptorius. 
The changes, microscopically studied, consist in a hyperplasia of the 
connective tissues, a granular degeneration, atrophy, and disappear- 
ance of the proper nerve-elements, the accumulation of fat-cells, pig- 
ment, and corpora amylacea. The posterior roots are also affected by 
a fibroid change — the connective tissue undergoing development, the 
nerve-fibers wasting. 'Not all parts of the posterior columns are equally 
affected : in the lumbar region the external division, in the cervical the 
inner and middle division or the columns of GoU are chiefly diseased. 
Similar alterations take place in the gray posterior horns, and exten- 
sion of the morbid process ultimately is effected to the lateral columns. 
The spinal ganglia and anterior nerve-roots escape degeneration, as 
also the ganglia of the sympathetic system. The gray degeneration 
often attacks the optic nerves, sometimes the oculo-motor and the 
abducens. The joints undergo remarkable changes : the articular car- 
tilages disappear by absorption, the head of the bone and the articular 
cavity gradually flatten, atrophy, and are greatly changed from their 
normal appearance. 

Symptoms. — In a man of the middle period of life, apparently in 
good health, there appear from time to time severe pains in the body, 
hips, thigh, and leg. These are usually of two kinds — sharp, quick, 
lightning-like pains flying through the limb, and a feeling of muscu- 
lar pain, which leaves a sensation of soreness. These pains at first are 
occasional but after a while they become paroxysmal and somewhat more 
frequent, and may, by the time the other symptoms are defined, be 
present more or less every day, although they may disappear for weeks 
at a time. The pains are increased by cold, especially by cold and 
dampness combined, and are worse in winter. At or before the onset 
of the pains there is a marked increase in the sexual appetite, and men 
are driven to commit excesses to which they had previously been stran- 
gers. The period of pains, with or without increased sexual inclina- 
tion, lasts a variable period, from a few weeks to several years, and is 
very often diagnosticated and treated as rheumatism. These pains 
are most severe in those parts destined to become ataxic first, usually 
the lower limbs. The next symptom is dq:)lopia, which appears unex- 
pectedly and after a variable period of a few weeks or a few months, 
disappears as unaccountably, although the change is very often attrib- 
uted to the remedies of some oculist consulted by the patient. Besides 
the visual disorder from this cause, the eyesight gradually becomes 
dim (amblyopia), and further on, the gelatiniform degeneration attack- 
ing the optic nerve, vision is lost (amaurosis). During this period the 
salacity, which was at first active, begins to decline and nocturnal sem- 
inal losses occur. There is also less and less ability to satisfy the de- 
sire, the sexual congress becoming unsatisfactory, the erections inade- 
44 



658 



DISEASES OF THE NERVOUS SYSTEM. 



quate, the ejaculation premature, and more or less pain taking the place 
of the pleasurable sensations, and finally complete impotence results. 
The first stage, according to the definition of Dnchenne, consists of 
three symptoms : pains, ocular disorders, anaphrodisia. As already 
remarked, the duration of this stage varies within wide limits — from 
a few months to several years, and then begin the symptoms charac- 
teristic of the so-called second stage : numbness ; ataxia of the muscu- 
lar movements of the inferior extremities ; cutaneous and muscular 
anaesthesia. In the bottoms of the feet the numbness includes a sen- 
sation as if cotton-wool or a cushion were interposed between the feet 
and the floor ; the constricting girdle sensation of spinal diseases is 
experienced around the body at different heights ; the limbs, thighs 
especially, feel as if embraced by a tight-fitting cuirass ; the severe, 
lightning-like pains rather increase than diminish ; the sense of touch 
is impaired, so that the points of the gesthesiometer can be felt as two 
only when they are very far apart ; impressions of irritation are slow 
to reach the centers of consciousness ; the sense of pain declines and is 
entirely abolished, but this latter may be at particular points only ; the 
sense of pressure and the sense of temperature are diminished. As 
regards the motor functions, we find the following characteristic phe- 
nomena : the " knee-jerk " or patellar tendon reflex is found to be ab- 
sent ; at first the limbs are easily fatigued and the movements are uncer- 
tain, so that in walking the gait has an unsteadiness like that of slight 
alcoholic intoxication, and these unfortunates are often suspected of 
indulging in this vice ; a sense of insecurity and often of helplessness, 
as when a carriage is approaching rapidly, or walking on a mar- 
ble or tiled floor, or in the obscurity of the evening, is experienced ; 
the ataxic phenomena increase so that they can not stand with the 
eyes closed, and in walking the feet describe a semicircle, the toes 
pointing upward and outward, the heels coming down with a stamp. 
An examination of the muscles now discloses that the disorder of loco- 
motion is an ataxia ; the muscles are not weak at first, and very great 
ataxia may coexist with complete retention of muscular power, but 
presently some of the muscles become paretic, and ultimately there 
may be paralysis with wasting. They can not at first walk without 
the aid of vision ; after a time the assistance of a cane is needed besides 
their eyes, then two canes are found necessary, and finally walking 
has to be abandoned. In Duchenne' s rather arbitrary arrangement 
the third stage consists in the extension of the sensory and motor dis- 
turbances to the upper extremities. The order of phenomena is as fol- 
lows : pains, numbness, first in the ulnar-nerve region, then extending 
to all the fingers, troubles of coordination, inability to use the knife 
and fork, to fasten a button, etc. The reflexes are variously affected 
— sometimes increased, sometimes lessened, sometimes wanting ; but 
the absence of the patellar tendon reflex is one of the most character- 



POSTERIOR SPINAL SCLEROSIS. 



659 



istic signs, so very rarely is it wanting in health, and so constantly is 
it not found at an early period of this disease. According to Buz- 
zard * it is absent in 96 per cent, of the cases. Electro-contractility is 
increased or normal, and reduced or lost when muscles degenerate. 

During the progress of the case, usually the vegetative functions 
are well performed. The appetite remains good, and the nutrition 
does not fail ; the patients often having a rosy countenance and a 
self-satisfied expression, which lends countenance to the theory of 
secret drinking. The mental functions continue unaffected, and the 
moral state is one of contentment, although there may be great de- 
pression of spirits. There are peculiarities in the symptoms, not in- 
cluded in the preceding description, to which some attention should be 
paid. The anaesthesia of the soles of the feet is an element in the 
disorders of movement in walking. Some patients with entire anal- 
gesia, so that a pin can be driven into the flesh without any sensation 
whatever, suffer agony with a gentle touch, as the brushing of a wo- 
man's dress against the legs. It is in spots that such sensations exist. 
The place where a lightning-pain has just been felt often burns for 
some time after. One of the most disagreeable disorders of sensation 
is the feeling of " fidgets," a peculiar unrest which impels to move- 
ment. The muscular sensibility is much reduced. The muscular 
sense, the knowledge of the position of the members, and the appre- 
ciation of weight and resistance, are all reduced or abolished, and con- 
sequently the disorders of muscular action of every kind are enhanced. 
The ataxia of movement is particularly well exhibited when the patient, 
lying recumbent, is told to touch objects with his foot. The move- 
ments are in jerks, great energy is put into them, but the direction is 
irregular and apparently purposeless. Ataxia affects the muscles of 
the eye, as well as of the extremities, producing the effect called nys- 
tagmus, disordered accommodation, and changes in the size of the 
pupils. Friedreich's bilateral nystagmus consists of jactitating move- 
ments in a vertical, horizontal, or oblique direction, not when the eye 
is at rest, but when an attempt is made to fix it. Besides these motor 
disturbances, vision is affected by gelatiniform degeneration of the 
optic nerve, in a variety of ways — in respect to the size and sharpness 
of the field of vision and the appreciation of colors, the ultimate result 
being white atrophy of the optic disks. Various trophic alterations 
occur during the course of locomotor ataxia, especially toward the end. 
The most important, which has already been referred to, are the joint 
affections, beginning usually in the knee-joint. These changes may 
indeed begin before the ataxia, during the first stage, and involve the 
shoulder, elbow, and wrist, as well as the knee and hip. There occurs 
first, in the joint, swelling due not to any inflammatory process, but 



* "Diseases of the Nervous System," p. 138. 



660 



DISEASES OF THE NERYOIJS SYSTEM. 



the mere accumulation of fluid, without pain or tenderness. The swell- 
ing may spontaneously disappear, but usually important and destructive 
alterations occur in the joint, the cartilages are destroyed, the ends of 
the bones worn off, and partial and entire luxation results.* The bones 
of the body of an ataxic manifest an extreme fragility and break easily. 

Course, Duration, and Termination.— Beginning obscurely and de- 
veloping slowly, it may be years before the character of the symptoms 
will justify the attempt at a diagnosis. The first stage lasts from sev- 
eral months to several years. The ataxic disorders usually begin in 
the lower extremities, and the pains are most severe in the part or 
member destined to become ataxic. It occasionally happens that the 
incoordination begins in the upper extremities. The second stage is 
even more protracted than the first, and its duration is an affair of 
years. When extension takes place to the upper extremity, the prog- 
ress is usually more rapid. The whole duration of the disease is on 
the average seven years (Topinard), but many continue thirty years. 
The shortest duration of a well-observed and carefully recorded case 
is three years. The progress is affected by the seasons, the atmos- 
pherical conditions, and by the regimen. Sometimes ameliorations 
occur without any apparent cause, or the disease remains absolutely 
stationary for long periods ; then exacerbations are experienced. The 
final result may be determined by acute congestion or softening of the 
cord, by cerebral diseases, by extension to the anterior cornua and the 
evolution of progressive muscular atrophy, by gastro -intestinal inflam- 
mation, by cystitis and pylonephritis, by bed-sores, and by various 
intercurrent diseases. The most frequent of the intercurrent maladies 
is phthisis, for we find that, in a collection of forty-three cases, thirteen 
were terminated by consumption, four by broncho-pulmonary inflam- 
mations, two by enteritis, three by typhoid fever, etc. That a cure of 
a genuine case, extended to the second stage, is ever affected, seems 
very doubtful. That the disease may be arrested, after more or less 
damage has been inflicted, is perfectly true. The author has men- 
tioned a case in which all the symptoms of the second stage were pres- 
ent, and which recovered completely under iodide of potassium, but 
the patient was a gilder. 

Diagnosis. — The recognition of this disease is easy when fully 
developed. During the first stage, the pains may not be different 
from those of rheumatism or myalgia, but the occurrence of double 
vision and of sexual disorders should suggest their real character. At 
this period the sexual disorders are confounded with " seminal weak- 
ness," but the diagnosis ought to be made, by the pains, the double 
vision, and the time of life at which the nocturnal losses began. From 

* " Diseases of the Nervous System," by J. M. Charcot, Syd. Soc. ed., London, 1877, 
p. 97. See also "Spinal Arthropathies," by Weir Mitchell, "American Journal of the 
Medical Sciences," April, 1875. 



Q 



POSTERIOR SPINAL SCLEROSIS. 



661 



all acute affections of the spinal cord this disease is separated by the 
exceeding slowness of its development as well as by the character of 
the attendant phenomena. From chronic myelitis and all other affec- 
tions of the cord, accompanied by paraplegia, with or without wasting, 
locomotor ataxia is differentiated by the condition of ataxia. In the 
one, the muscles are paralyzed ; in the other, they are not paralyzed, 
but incoordinate. These coarse phenomena seem sufficient without 
entering into the numerous finer points of difference. 

Treatment. — If the disease is recognized early, before important 
changes have occurred in the spinal cord, the first of all remedies is rest, 
and as nearly absolute rest as possible. The results accomplished in 
this way are remarkable. The patient should avoid all use of his 
muscles, and should remain recumbent for weeks. The rest-cure in- 
volves the complete severance from all cares, occupations, and move- 
ments for a period of two or three months, and subsequently greatly 
modified occupation and movement for some months longer. The posi- 
tion should be on one side and toward the face as much as possible, 
and on a firm bed or lounge, without any constricting clothing. The 
diet must be light and simple, corresponding to the changed necessi- 
ties of the organism. Coffee, tea, tobacco, and alcoholic stimulants 
should be given up. Next to rest in importance is the cold-water cure, 
which may be well conjoined with the rest-cure, and thus serve a dou- 
ble purpose. Erb says the " thermal baths " are hurtful, but that the 
results of the " cold-water baths are extraordinarily favorable. . . . 
Of nineteen tabes patients who went through with the cold-water cure, 
sixteen experienced more or less benefit, two saw no improvement, and 
only one grew slightly worse." The temperature of the water must 
not be below 68° Fahr., nor above 88° Fahr., and the application should 
consist of the rubbing wet pack confined to the spine, the wet cold 
compress applied along the spine for some minutes, and cold sponging 
of the spine, all cold douches and full baths being avoided. The 
treatment may be conducted better at home, if the patients are pro- 
vided with the means. The springs of our mountain-regions of Vir- 
ginia, Pennsylvania, New York, etc., may be advised during the sum- 
mer and fall, the temperature and not the composition of the icater be- 
ing heeded. The author has seen a great deal of injury done by the 
hot springs of Arkansas in this disease. The third remedy is galvan- 
ism, direct continuous currents to the spine, labile applications to the 
extremities for the relief of pain, faradic currents to wasting muscles, 
and to the bladder if paralyzed. As regards the internal medicines, 
the use of iodide of potassium is proper in every case for a short time, 
lest there may be a syphilitic or metallic lesion of the cord. If no 
results follow in two or three weeks, a continuation of the remedy will 
not be advantageous. If there be a decided decline of the vital pow- 
ers, the best results are obtained from lactophosphate of lime and cod- 



662 



DISEASES OF THE NERYOUS SYSTEM. 



liver-oil. Nitrate of silver has been serviceable in many cases, and is 
placed first as a remedy by some great authorities, but the danger of 
staining the tissues of the body is very great. The author has had 
excellent results from the persistent use of the chloride of gold and 
sodium, and when there is reason to suspect a syphilitic taint, he has 
conjoined with it minute doses of corrosive sublimate. Arrest of the 
disease has been, apparently, obtained in some instances, no further 
developments occurring after one and two years of close observation. 
Phosphorus has produced good effects in the hands of Dujardin-Beau- 
metz, but has been less useful in the experience of others. Nerve- 
stretching has now been done in many cases, with much relief. The 
sciatics are exposed, and stretched by the finger or a hook placed un- 
der them. Unfortunately, the first encouraging experiences have not 
persisted, and the operation of nerve-stretching, as a remedy for tabes, 
is rapidly declining in professional estimation. 

IiATi3RAL SPINAL SCLEROSIS. 

Definition. — This term is employed for uniformity to express a dis- 
ease having similar lesions to those of posterior spinal sclerosis but a 
different seat. By Charcot this disease is named spasmodic tabes dor- 
salis, and by Erb spastic spinal paralysis. 

Pathogeny, — Lateral spinal sclerosis develops under the same con- 
ditions as posterior spinal sclerosis. The site of the lesions is the lat- 
eral white columns, and the changes consist in the gray gelatiniform 
degeneration. There occurs an interstitial hyperplasia of the connec- 
tive tissue, and an atrophy of the proper nerve-elements. Although 
it chiefly affects the posterior part of the lateral column, it may ex- 
tend forward to the anterior horn (its external angle), posteriorly to 
the anterior gray matter, and internally to the deepest portion of the 
lateral columns (Charcot). Secondary degeneration of the lateral col- 
umns, which occurs in certain cerebral diseases, is found on one side 
only. In the disease described by Charcot under the name amyotro- 
phic lateral sclerosis, to the sclerosis of the lateral columns are added 
atrophy and disappearance of the multipolar ganglion-cells of the ante- 
rior cornua. This form of spinal sclerosis is situated in the cervical en- 
largement by preference (Erb). Lateral spinal sclerosis has its seat 
in the whole length of the cord — from the lumbar region up to the 
medulla oblongata. 

Symptoms. — The symptoms of this disease are peculiarly striking, 
in that paraplegia exists with motor irritation. Before the motor 
symptoms there may be present such sensory disturbances as pain in 
the back, tingling, formication, and "tearing pains," but these are 
usually transient. The irritation symptoms are motor, and consist of 
jerking and twitching, cramps, and stiffness of the muscles, felt esi^e- 



LATERAL SCLEROSIS. 



663 



cially after fatiguing exercise, and at night on lying down. The 
muscles gradually become very tense, and certain movements diffi- 
cult in consequence. Because of the continuous tonic contractions 
of the muscles the knees seem stiff, the step is shortened, and the 
legs approximated. The gait is a hop, the patient stepping on the 
toes, and showing a tendency to fall forward. This peculiarity of 
muscular movement is due, not altogether to the tonic extension state 
of the muscles, but to paresis. At first there is a feeling of heaviness 
and weakness, the muscles becoming very tired on slight exertion, 
and this passes on into paresis, only in very rare cases into paralysis. 
When the point of the foot rests on the floor, the patient sitting, a 
tremor of the limb is produced. The tendon reflexes in this disease 
are much exaggerated. The sensibility is unaffected ; there is no 
atrophy of the muscles ; and the functions of the rectum, bladder, and 
sexual system remain unaltered. The disease, beginning below, ex- 
tends gradually upward. When the muscles of the trunk become 
affected, sitting up, or rising from the recumbent to the upright posture 
becomes difficult, finally impossible. When the arms are involved, 
the same combined weakness and rigidity, increase of the reflexes, 
paresis and contractures occur. But there are no symptoms of ataxia, 
and paralysis only rarely results. Sometimes the disease assumes a 
hemiplegic form, passing from one lower extremity to the correspond- 
ing upper extremity. When the disease completes its development, 
so to speak, it remains nearly stationary for many years, yet in most 
cases, ultimately, the contractures increase, and the paralysis becomes 
complete, and the patient is then entirely disabled. Nevertheless 
the malady does not prove fatal of itself, the termination being by 
some intercurrent disease. In that form of anterior spinal sclerosis 
in which the lesions involve the anterior cornua, and which is accom- 
panied by progressive muscular atrophy, the symptoms present are 
those of anterior spinal sclerosis and progressive muscular atrophy.* 
As the anatomical site of the disease is the cervical portion of the 
cord, the symptoms first produced are those of the upper extremities. 
The muscles of the arms are occupied by fibrillary contractions, are 
wasted, paretic, but still retain the electro-contractility. The muscles 
of the arms, jaws, and neck are also in a state of tonic contraction 
passing into contractures, which ultimately disappear when the 
changes in the muscles are complete. In from four months to a year 
both arms are fully affected, and then extension takes place to the 
lower extremities. The same phenomena of paresis and rigidity with 
wasting take place in the lower extremities, but the bladder and rec- 
tum are not affected. Then occur also in the lower limbs the fibril- 

* " Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et des 
faisceaux anterolateraux de la moelle epiniere," par Mil. J. M. Charcot et A. Joffroy, 
"Archives de Physiologic," vol. ii, 1869, j). 354, et. seq. 



664 



DISEASES OF THE NERVOUS SYSTEM. 



lary contractions and clonic spasms, with permanent muscular rigidity, 
which are characteristic of this disease. In the third stage, the field 
of morbid activity is transferred to the medulla oblongata. Respira- 
tory and circulatory disturbances then ensue, and death speedily 
occurs. The whole course of this disease is completed in from two 
to three years. 

Diagnosis. — The main points of diiference between posterior and 
anterolateral spinal sclerosis have been referred to in passing. The 
presence of the reflexes, the absence of all symptoms of ataxia, weak- 
ness instead of incoordination, the contractures and clonic spasms — all 
characteristic of lateral, are wanting in the posterior sclerosis. 

Treatment. — The principles and methods of treatment are the same 
as in posterior spinal sclerosis, which have been sufficiently set forth in 
the preceding chapter. 

INFANTILE PARALYSIS— POLIOMYELITIS ANTERIOR ACUTA 

OP ADULTS. 

Definition. — By infatitile paralysis is meant a peculiar form of spi- 
nal paralysis, occurring in children suddenly, and due to an inflamma- 
tion of the anterior horns of gray matter. It is now known that the 
same form of disease occurs in adults also, though much less often. 

Causes. — Infantile paralysis, as the name implies, is a disease of 
early life, and occurs most frequently from six months to the fourth 
year ; but precisely the same form of disease occasionally is encoun- 
tered up to sixty years of age, so that the term proposed by Kussmaul 
— poliomyelitis anterior acuta — is more appropriate. Besides age, lit- 
tle is known as to the causes producing this disease. The influence of 
summer heat seems established by the observations of Sinkler.* As 
cases frequently occur during the course of convalescence from the 
exanthemata, and other acute febrile afl^ections, a causative relation is 
supposed to exist between them. The important negative fact, that 
the influence of heredity can not be traced, must be stated. 

Pathological Anatomy. — The naked-eye appearances furnish no ex- 
act information, and may be entirely negative. On microscopic ex- 
amination, important changes are found in the anterior horns of gray 
matter, in the dorso-lumbar and cervical enlargements of the cord. 
The change consists in an inflammatory softening ; the nerve-elements 
are disassociated by an exudation containing numerous granulation cor- 
puscles and free nuclei ; the neuroglia undergoes hyperplasia, and the 
blood-vessels are abnormally distended ; the multipolar ganglion-cells 
have wasted, and many disappeared, while those remaining are in 
various stages of atrophic degeneration. The softening occurs in cer- 



* " American Journal of the Medical Sciences," vol. Ixix, p. 348, 



INFANTILE PARALYSIS. 



665 



tain areas, from a half -inch to an inch in length, and on both sides, or 
on one side only, and especially in the dorso-lurabar enlargement. 
The softening extends a little posteriorly and laterally, and sclerotic 
degeneration also occurs in the adjacent antero-lateral columns. Sim- 
ilar changes take place in the anterior roots. Extensive wasting, atro- 
phic degeneration, and sclerosis, occur in all cases and after many 
years. The anterior nerve-roots are thin, atrophied, and translucent, 
and more or less degeneration takes place in the filaments of the pe- 
ripheral nerves. The muscles to which the nerves are distributed 
undergo very serious alterations, which consist in an increase of the 
connective tissue, the formation of numerous fat cells and granules, 
and the degeneration and disappearance of the muscular fibers. The 
bones of the paralyzed members cease to grow, and degenerate more 
or less, the cancellated structure being relatively increased, and the 
fatty tissue also. Important changes occur in the joints ; the articu- 
lar surfaces are atrophied and eroded, the ligaments thinned and 
stretched, the articulations relaxed. By reason of these atrophic 
changes great deformities, the worst forms of club-foot, are produced. 

Symptoms. — The usual onset of this disease is a fever, which lasts 
a day or two, and on recovery from which it is observed, with sur- 
prise, that the child is paralyzed. The fever may be accompanied 
with headache, pain in the back and limbs, with vertigo and delirium, 
in some cases with convulsions. Dr. Mary Putnam-Jacobi * has ana- 
lyzed one hundred and sixty-three cases, and finds that there are sev- 
eral modes of onset. In twelve of these cases the paralysis occurred 
suddenly without any prodromes ; in some cases the paralysis appears 
in the morning after a quiet night, or between morning and evening, 
without symptoms ; in the majority of cases there is an attack of fever 
lasting two or three days ; in some, merely nausea and vomiting, and 
in still others the paralysis is preceded by convulsions. What symp- 
toms soever may precede the palsy, they subside in a day, or in two or 
three days, and the health seems restored, but one limb or several are 
found to be paralyzed ; or one leg is limp and motionless, and in an hour 
or two the other leg is found to be in the same condition ; and, in the 
course of the next twenty-four hours, the arms may also be paralyzed. 
From the beginning of the symptoms until the paralysis is completed, 
rarely more than a week is required. The bladder may participate in 
the paralysis, and the urine be retained, or there may be incontinence, 
but the bladder is not permanently affected, and these troubles disap- 
pear in a few days or weeks. Sensibility is not affected. The pa- 
ralysis is complete at once, and soon begins to lessen, some restoration 
of power taking place in from one to three weeks, which may gradu- 
ally go on until the paralyzed parts are completely restored m the 



" The American Journal of Obstetrics," June, 1874. 



666 



DISEASES OF THE NERVOUS SYSTEM. 



course of a few months. During this period the electro-contractility 
and the nutrition of the muscles are not affected in this group of cases, 
although the muscles are flabby and soft. Most of the cases behave 
differently. Improvement begins as in the cases just narrated, but 
it proceeds to a certain point only ; some of the members recover en- 
tirely, leaving one or more or a single group of muscles affected. 
Thus the arms may be restored and the lower limbs continue paralyzed, 
or one arm or one leg may remain disabled. Rarely is one half of the 
body (hemiplegia) affected, and, if such be the case, the cause is to be 
sought within the cranium. When an arm is alone affected, the ex- 
tensors of the arm and lingers are paralyzed ; when the lower limbs 
are involved, the disability is in the extensors of the thigh (the psoas, 
Rosenthal), or in the muscles supplied by the peroneal nerve. The 
muscles remaining paralyzed are affected permanently, and by a rap- 
idly progressive atrophy ; the tendon and other reflexes and the elec- 
tro-contractility to the faradic current are abolished (reactions of de- 
generation). The temperature of the paralyzed parts falls several de- 
grees ; they become cool to the touch, and present a blue, cyanosed 
appearance. The muscles waste till there is nothing but connective 
tissue and fat, the joints change in form and structure, the growth of 
the limb is arrested, and, if one of the lower limbs is affected, assum- 
ing often one of the forms of club-foot. Seguin* has given a careful 
analysis of many of the cases of spinal paralysis (poliomyelitis anterior 
acuta), which have been published. The following symptoms he re- 
gards as characteristic : " Dysesthesia, and slight temporary anaesthe- 
sia, paresis and akinesis, both these symptoms affecting the extremi- 
ties, and in rare cases the eyes, face, tongue, and throat ; not affecting 
the respiratory muscles, nor those of the back and abdomen, nor the 
bladder, nor the sphincter ani. Muscular atrophy in the paralyzed 
parts. Loss of electro-muscular contractility (to faradic current) in 
the atrophied muscles. A strong tendency to spontaneous retroces- 
sion of the palsy, and to spontaneous cure. The important negative 
characters of this affection are : absence of palsy of the bladder, or of 
the sphincter ani, or of the respiratory muscles ; no bed-sores ; no 
great and extensive anaesthesia ; no spinal epilepsy." 

Acute Poliomyelitis of the Adult.— Although essentially the same 
disease in the adult as in children, it presents in the former some 
special characteristics, owing to the difference in bodily development. 
It begins with more or less intense headache, backache, nausea and 
vomiting, hebetude of mind, and even mild delirium. Various disor- 
ders of sensibility are noted by the adult when they can not be got 
from children. These disorders of sensation are numbness, formica- 
tion, tingling, in the parts subsequently paralyzed. There is usually 

* "Spinal Paralysis of the Adult," New York, 1874, p. 27. 



INFA^s^TILE PARALYSIS. 



667 



considerable fever, the temperature rising to 102°-103° Fahr., but this 
symptom may be wanting. The paresis or paralysis comes on in a 
few hours after the beginning of the symptoms, and is widespread as 
a rule, but may be confined to a few muscular groups. The affected 
muscles are flaccid, and waste ; the reflexes are much less active or dis- 
appear entirely ; the reactions to the f aradic current are feeble or are en- 
tirely abolished, the reactions of degeneration appearing. In the adult, 
however, more frequently than in children, the muscles retain their 
power of response to faradic stimulation, although in a feeble degree. 

When the systemic disturbance subsides, in a few days, the paresis 
and paralysis manifest a tendency to restoration, which may, indeed, 
be complete after some weeks or months, but frequently some of the 
muscles undergo atrophic degeneration, with the characteristic electrical 
reactions, and deformities result, but never to the same extent as in chil- 
dren. In a majority of the cases, the resulting paralysis involves all 
of the members, or both of the upper, or both of the lower extremities. 
Paresis of the sensory nerves may be present at first, but this soon dis- 
appears, and thereafter sensibility continues normal. The special 
senses remain unaffected. Some weakness of the bladder is noted at 
the outset, but this is a temporary symptom. 'No change takes place 
in the sexual functions. 

Course, Duration, and Termination. — The course of the disease is 
very uniform. The mildest cases, in which restoration of power begins 
in a few days, recover entirely in a few weeks or in a month or two. 
These cases have been designated " temporary paralysis." Other cases, 
in which a single member or a group of muscles remains paralyzed 
after the efforts at restoration have ceased, may regain the lost power 
in from two to six months. If the restoration does not take place 
within this time, it becomes less and less likely with the increasing 
duration of the case. Partial restoration is the rule even in unfavor- 
able cases. Much depends on the treatment. So far as danger to life 
is concerned, the prognosis is always favorable. So far as ultimate 
entire restoration is concerned, the prognosis is doubtful. Persistent 
and rightly conducted electrical treatment may accomplish much even 
in the worst cases. 

Diagnosis. — The first point in diagnosis is the condition of the 
paralyzed muscles. If wasted, how far do the muscular elements exist ? 
This is ascertained by electrical tests. In these cases the muscles do 
not respond to a faradic current, but will contract on the application of 
a weak and slowly interrupted galvanic. Muscular contraction is the 
proof of the presence of the muscular elements. By the use of the 
harpoon, some portion of the tissue may be withdrawn and submitted 
to a microscopic examination. Infantile paralysis may be confounded 
with acute myelitis, hcemorrhage into the cord, progressive muscular 
atrophy, paralysis from cerebral affections in childhood 2iT\di paralysis 



668 



DISEASES OF THE NERYOUS SYSTEM. 



from local nerve-lesions. From myelitis the distinction is made by 
the stage of excitation affecting sensibility and motility, and the stage 
of depression also affecting sensibility and motility and the bladder. 
From haemorrhage, the distinction is made first on account of its 
rarity, next the suddenness of the attack, sensibility being destroyed 
as well as motility, usually, and the sphincters paralyzed. From pro- 
gressive muscular atrophy, the distinction is made by the age of the 
subject, the slow development, and the affection of isolated muscular 
groups in turn. From cerebral lesions, the distinction is made by the 
pronounced cerebral symptoms, by the hemiplegia, by the electrical 
reaction, the electro-contractility rather heightened than lost, and by 
the appearance and condition of the paralyzed members. From pa- 
ralyses due to local injury of nerve, the distinction is made by the his- 
tory of the case, the evidence -of injury, by the absence of fever, by 
the diffusion of the paralysis at first, followed by localization. 

Treatment. — During the attack of fever with which the disease 
begins, only symptomatic treatment is proper, since a diagnosis is not 
possible. When paralysis has occurred the damage to the cord is com- 
plete, but, as the functional disturbance is more extensive than the 
symptomatic expression of the real lesions, the improvement which 
follows from the first paralysis is simply the disappearance of the 
merely functional troubles. Any active treatment, therefore, insti- 
tuted with a view of combating an inflammation, is improperly ap- 
plied. The problem is to prevent further destruction of the gray mat- 
ter, and to restore damaged but still functionally capable tissue. The 
remedies best adapted to accomplish this, and which in the author's 
hands have acted best, are quinine and belladonna (from a fourth to 
four grains, according to age, of quinine, and from -^-^ to \ grain of bel- 
ladonna extract) ; hot douche to the spine and tepid wet packs ; the 
application of galvanism, inverse current, stabile, large volume and 
low intensity, and rest, as nearly absolute as possible, until the period 
of restoration. When the period of improvement comes on, the mus- 
cles mitst be faradized, if they react to the faradic current, or gal- 
vanized if they react only to the galvanic current. Massage is suitably 
combined with electrical treatment. The wasted muscles are much 
improved by aquapuncture ; still more by the intramuscular injection 
of strychnine — grain) two or three times a week. The injec- 
tions of strychnine should not be practiced until after the period of 
restoration — the stationary period. 

PROGRESSIVE MUSCULAR ATROPHY. 

Definition. — By the term progressive muscular atrophy is meant a 
gradual and progressive wasting of the voluntary muscular system, 
which pursues a certain defined course. 



PKOGRESSIYE MUSCULAR ATROPHY. 



669 



Causes. — ^^umerous examples of hereditary transmission, some of 
them very remarkable, have been reported. The male sex is much 
more susceptible, and this is equally the case when the disease is he- 
reditary. The most active period of life — from thirty to fifty — is the 
period of greatest liability ; but youth and early manhood are by no 
means exempt, cases occurring before ten. Powerful muscular exer- 
tion, or overstrain of a group of muscles in certain occupations, seems 
to excite the disease ; and in children the disease is invited to the low- 
er limbs by prolonged effort on the legs. Exhausting diseases, the 
poisons of lead and syphilis, and certain dyscrasise, seem to exert an 
influence in developing the disease. Exposure to cold and mechanical 
injuries have apparently given rise to progressive atrophy. 

Pathological Anatomy. — The morbid alterations are of two groups 
— spinal and muscular. The changes in the spinal cord are similar to 
those which take place in the spinal arthropathies in general, i. e., 
atrophy and degeneration of the anterior columns, wasting and disap- 
pearance of the multipolar ganglion-cells, of the anterior horns, hyper- 
plasia of the neuroglia, corpora amylacea, granule-cells and fat-corpus- 
cles. The anterior roots are similarly affected — are wasted, atrophied, 
and degenerated. In one third of the reported cases in which the cord 
was examined, no changes were found of any kind. The alterations 
in the muscles have been most elaborately studied by Friedreich,* who 
holds to the muscular origin of the disease. He asserts that the initial 
change consists in an inflammation with hyperplasia of the interstitial 
connective tissue uniting the primitive bundles. Morbid changes oc- 
cur in the primitive bundles : proliferation of the nuclei and multipli- 
cation of the muscular corpuscles. Wasting of the muscular substance 
goes on, pari passu, with the increase of the connective tissue, and fatty 
degeneration contributes to it. The final result is, that the muscle is 
converted into a mere fibrous band with numerous fat-cells, the devel- 
opment of this latter material taking place outside of the muscular ele- 
ments and in the newly formed connective tissue. The theory of Fried- 
reich, which he maintains with remarkable skill and learning, is that the 
disease begins in the muscles, the intramuscular nerves are next affected, 
and an ascending neuritis conveys the morbid process to the spinal cord, 
which becomes in turn diseased. The other view is, that the changes 
in the muscles are secondary to the morbid process in the spinal cord, 
especially in the multipolar ganglion-cells of the cornua.f 

Symptoms. — According to Friedreich's statistics, of one hundred and 
forty-six cases, there were one hundred and eleven instances of the dis- 

* "Ueber progressive Muskelatrophic," etc., von Dr. N. Friedreich, Berlin, 1873, cap. 
ii, p. 46. 

f Charcot and Joffroy, "Archives de Physiologic," vols, ii and iii, op. ci,t. A. Hayem, 
ibid. See also, as explanatory of spinal affections consecutive to nerve-injuries, A. Vul- 
pian, ibid., p. 221. 



670 



DISEASES OF THE NERVOUS SYSTEM. 



ease beginning in the right upper extremity, twenty-seven in the lower, 
and eight in the lumbar muscles. Sometimes the tongue, sometimes 
the palate muscles, an example of which the author has seen, are first 
affected. The first dorsal interosseus is usually the first muscle at- 
tacked in the upper extremity, then the muscles of the thenar and hy- 
pothenar eminence, the deltoid, etc. Sometimes the pectoralis major 
and serratus magnus are the first to undergo atrophy. In children the 
lumbar muscles are usually the first to atrophy, the degeneration taking 
the form of pseudo-hypertrophic. The loss of volume which the mus- 
cles undergo is not always a measure of the real degeneration, since a 
very considerable hyperplasia of the fatty tissue sometimes takes place, 
with the effect to increase the apparent size. The next symptom is 
fibrillary contraction : the muscle undergoing atrophy so long as it 
remains, is agitated by fine tremors, which consist in waves or oscilla- 
tions of movement of the muscular fibrillse. If, now, the muscles of 
the diseased hand are tested by the dynamometer, they will be found 
extremely weak as compared with the sound hand. The hand also 
becomes greatly deformed, rigid, and claw-like, presenting the appear- 
ance of a bird's talons. The electro-contractility is preserved so long 
as muscular fibers remain to be stimulated, but the reaction to the gal- 
vanic persists for some time after the faradic excitability has disap- 
peared. In most patients a good deal of pain is experienced in the 
muscles about to be affected and during the process of wasting, but 
the sensibility to pain and to temperature diminishes to below normal 
in the last stages. The temperature of the wasted parts is also reduced 
several degrees, and they are cold to the touch ; and the integument 
appears normal or pale, or blue, and cyanosed. The perspiration is 
usually increased in the affected member or part, and sometimes gen- 
erally. Changes in the joints, comparable to those which take place 
in locomotor ataxia and other spinal diseases, are also observed in pro- 
gressive muscular atrophy.* Changes in the pupil and other oculo- 
motor phenomena occur when' progressive muscular atrophy" is asso- 
ciated with glosso-labio-pharyngeal paralysis. This disease may be 
accompanied with fever during the first weeks or months, often asso- 
ciated with the joint:lesions. How far this is accidental or a necessary 
part of progressive muscular atrophy does not appear to be well under- 
stood. 

Course, Duration, and Termination. — The course of this disease is 
extremely protracted in many cases. The manner of spread of the 
myopathic process is not in accordance with a uniform plan. It some- 
times extends by contiguity of tissue, sometimes leaps over groups of 
muscles to attack distant muscles. The extension is limited by the 
larger joints. Beginning in the hand, an extension to the arm does 

* On this point consult Weir Mitchell's " Spinal Arthropathies," in " Aracrican Journal 
of the Medical Sciences," April, ISVo, p. 339. 



PROGRESSIVE MUSCULAR ATROPHY. 



671 



not take place ; some of the extensors of the forearm undergoing atro- 
phy, the muscles of the arm are not attacked ; the deltoid and arm 
muscles affected, the elbow-joint is not passed ; similarly in atrophy of 
the leg-muscles, the knee-joint seems to prevent extension to the thigh. 
Some muscles are never affected ; those of the head are not often ; and, 
when the tongue and lip muscles and the laryngeal muscles are affected, 
the disease is complicated with glosso-labio4aryngeal paralysis. The 
diaphragm and the respiratory muscles and the accessory muscles of 
respiration are finally invaded. Death then ensues by hypostatic con- 
gestion and oedema of the lungs. When the larynx is invaded, the 
voice is lost, and there is difficulty of breathing from cessation of the 
laryngeal movements. The muscles of the ear may also be invaded, 
and impaired hearing result. Friedreich gives a remarkable example, 
pictorially represented, of a man all of whose voluntary muscles are 
wasted, and who seems to retain alone the power of breathing. The 
march to this end. is exceedingly slow, unless, as is not unfrequently 
the case, the morbid process involves the anterior cornua of the me- 
dulla oblongata, the effects of which have already been described. At 
first no trouble is produced by the wasting of the muscles of the 
extremities ; the general health does not suffer ; the powers of body 
and mind are otherwise adequate to their work. Sometimes the dis- 
ease is arrested, and remains stationary for years. A few cases are 
terminated by bed-sores ; many by intercurrent maladies, of which 
pulmonary tuberculosis is the chief. 

Diagnosis. — A fully formed case can never present any difficulty in 
this respect, but at the initial period there may be doubt whether the 
wasting is due to local injury, injury of the nerve-trunk, or the result 
of rheumatism. The distinction rests on the pains, the fibrillary trem- 
bling, and the absence of any local cause to account for the atrophy. 

Treatment. — I^othing has ever been accomplished by the use of 
internal medicines. The author has apparently effected great improve- 
ment in a case, confined as yet to the left upper extremity, by the 
injection of glycerine solution into the wasting muscles. The strength 
of the solution is one third glycerine, and it is injected three times a 
week. The two remedies of unquestionable utility are galvanism and 
massage. The author has had good results from galvanism, and he 
can not share the despondency of authors generally in regard to its 
utility. Erb reports favorably as to the good effects of the galvanic 
current. Strong currents must be used to excite vigorous contractions 
for a brief period — two minutes. A descending current should also be 
applied to the whole length of the spine, daily, for a minute or two. 
Massage, using with friction a fat, preferably lard, is also highly ser- 
viceable. This should consist of friction, kneading, and tapping the 
muscles. Hot douches to the spine and the rubbing w^et pack for the 
affected members are also to be highly commended. 



672 



DISEASES OF THE NERVOUS SYSTEM. 



PSEUDO-HYPERTROPHIC PROGRESSIVE MUSCULAR ATROPHY. 

Pathogeny and Symptoms— This disease differs from progressive 
muscular atrophy, in the remarkable fact that the atrophied muscles 
increase in size, and are apparently hypertrophied, because of an hyper- 
plasia of the connective and fatty tissue. The anatomical change con- 
sists, in brief, in a proliferation of the connective tissue between the 
fibrilla (Friedreich) and the adventitia of the small vessels. The 
newly formed connective tissue is remarkable for the number of its 
cells and nuclei, which are transformed into fat-cells. As the connec- 
tive tissue develops the muscular elements disappear, or at least only 
in part remain, much altered, and thinner. Now and then are encoun- 
tered some muscular fibers which have undergone hypertrophy. The 
muscular elements are also invaded by an irritative process, become 
granular and degenerate, so that the atrophy is not wholly a simple 
atrophy from overgrowth of the connective tissue. When the process 
is complete the muscles present a grayish or yellowish-white appear- 
ance, and can hardly be distinguished from the adjacent fatty and con- 
nective tissue. 

This disease occurs almost wholly in childhood, and before ten 
years of age. In eighty cases, it began from the first to the fifth year 
in forty-five ; from the sixth to the tenth, twenty-two times ; from the 
eleventh to the sixteenth, eight times ; and in five cases it occurred 
from the twenty-second to the forty-third year (Erb). Hereditary in- 
fluence plays a very important part in the development of the disease. 
Other causes have been assigned, and probably with little reason, for 
all the facts go to prove the existence of a peculiar neurodiathesis. 

The morbid process begins in the lower limbs — chiefly in the legs, 
although it may begin in the thighs. Before the hypertrophic en- 
largement manifests itself, muscular weakness has occurred ; fatigue is 
quickly experienced ; the legs trip easily and give way ; the gait is 
awkward. After a time a child thus affected is not able to rise, when 
down, unless aided, and can not walk unless steadied ; the gait assumes 
a straddling manner, somewhat like that of a duck, and when the 
thigh-muscles are affected he can not rise unless he supports his thighs 
by his hands, and in sitting down can not control the act, but plumps 
down suddenly. When recumbent, the legs are wide apart, the soles 
of the feet turned toward each other, the heels drawn up, and the knee 
and hip joints flexed. All the movements of the foot are imperfectly 
executed, except flexing the toes ; the movements of the thigh are 
equally imperfect, except mere flexion of the knee. The position in 
standing is very characteristic : the lumbar portion of the spine is 
greatly incurved (lordosis), the dorsal portion bent outward (gib- 
bosity). The diminution in power offers a remarkable contrast to the 
enormous bulk of the affected members. If the disease attacks the 



ATROPHIC SPINAL PARALYSIS. 



673 



upper extremity, it takes the form of progressive muscular atrophy, 
and the two may exist together. Before the muscular tissue has disap- 
peared, the same fibrillary twitchings occur as in the other form of 
the disease. The electro-contractility declines progressively with the 
diminution of the muscular elements, and in this disease the more de- 
cidedly because of the great collection of fatty and fibroid tissue over- 
lying the muscular elements. There is more or less pain experienced 
by these patients, in the back, and through the parts to become affect- 
ed. The temperature declines several degrees in the hypertrophied 
and atrophied parts. The termination of these cases has been by some 
intercurrent disease, usually of the respiratory organs. 

CHRONIC? POLIOMYELITIS ANTERIOR— ATROPHIC SPINAL 

PARALYSIS. 

Definition. — As there is an acute poliomyelitis affecting the anterior 
columns, so there is a chronic disease of similar character, but possess- 
ing some distinctive features. It consists in a chronic atrophic degen- 
eration — a muscular paralysis with wasting and atrophy of the affected 
muscles — secondary to degeneration of the gray matter of the ante- 
rior horns. 

Causes. — While the acute anterior poliomyelitis attacks children 
more especially, although occasionally appearing in adults, the chronic 
affection occurs at the middle period of life — from thirty to fifty years 
of age. As very similar symptoms and lesions are caused by lead, 
copper, and some other metals, the modern use of these metals in do- 
mestic life may have a causative relation to this and corresponding 
nervous affections. Injury to the spine, excessive fatigue, exposure to 
cold and damp combined, sexual and alcoholic excess, have all been 
supposed to bring on this disease. In any case thus produced it is 
quite certain that a neuropathic type of constitution must have existed. 

Pathogeny and Symptoms. — The seat of the pathological changes 
and their general character correspond to fhose of acute anterior polio- 
myelitis. The multipolar ganglion cells are degenerated and wasted, 
the vessels are thickened, the perivascular lymph-spaces crowded with 
leucocytes, red corpuscles, and granular matter, and the anterior 
nerve-roots more or less advanced in atrophy. The paralyzed muscles 
exhibit the characteristic degenerative changes, consisting in atrophy 
and disappearance of the muscular elements, and the substitution of 
connective and fatty tissue. 

The symptoms develop rather insidiously, with a sense of fatigue 
and exhaustion of the lower limbs, pain in the back, loins, and hips, 
headache and some slight feverishness, with the anorexia and general 
malaise belonging thereto. Then some tingling, creeping, and crawl- 
ing sensations, "pins and needles," and distinct muscular weakness 
45 



674 



DISEASES OF THE NERVOUS SYSTEM. 



are experienced. The weakness gradually deepens into a paralysis, a 
group of muscles or an extremity loses its power entirely, and next 
other muscular groups, or a member, become paralyzed. As a rule the 
morbid process begins in a lower extremity and extends to the upper 
members, but the process may be reversed, and the paralysis beginning 
above may extend downward. The flexors of the foot first, the flex- 
ors of the leg and thigh next, and then the extensor of the limb are 
affected. In the upper extremity there is no regular order for the 
paralysis to occur : the muscles of the hand — the flexors of the fingers 
and hand ; again, the extensors of the forearm, are first paralyzed, 
and the process extends thence to the arm and shoulder-muscles, until 
all become paralyzed and wasting. Ultimately, the muscles of the back 
and of the abdomen, and sometimes, also, of the chest, are paralyzed, 
so that the breathing becomes difficult because carried on by the dia- 
phragm, and the expulsion of the faces and urine is inefficiently per- 
formed. When the paralysis reaches this extent, the patient is quite 
helpless, and can not maintain the sitting posture. The functions of 
organic life are, however, carried on in the normal manner. Diges- 
tion, assimilation, the circulation, the sexual functions, the bladder 
and rectum, remain unaffected. Sensibility is not impaired, and bed- 
sores do not form. The reflexes decline and disappear with the prog- 
ress of the changes in the spinal cord and muscles. The electric reac- 
tions are changed from the normal in harmony with the anatomical 
alterations. As the muscles atrophy, faradic excitability declines quan- 
titatively, and presently ceases. The galvanic excitability increases 
in accordance with the formulae of the reactions of degeneration. But 
galvanic excitability disappears finally in those muscles so far atrophied 
that none of the proper anatomical elements remain. 

Course, Duration, and Termination. — The progress of this affec- 
tion varies in rapidity between wide limits. In some cases paralysis 
supervenes rather suddenly soon after the initial symptoms appear ; in 
others, after the first weakness and heaviness of the lower limbs, 
months, even years, intervene before complete paralysis occurs below 
and extends to the upper limbs. In the cases which take a favorable 
direction, the upward extension of the morbid process is arrested. If 
the changes in the cord continue to advance, after a time the medulla 
oblongata is reached, and then there is experienced that group of symp- 
toms characteristic of disease of this part — as ataxia of speech, diffi- 
culty of swallowing, embarrassed respiration, cardiac failure, etc., and 
death from asphyxia. A considerable proportion of the cases improve : 
the upward extension of the disease is arrested ; the paralysis slowly 
lessens and voluntary power gained, the electrical reactions changing 
accordingly — first, the abnormal galvanic excitability gradually declin- 
ing, while the faradic excitability is recovered. It is by almost imper- 
ceptible gradations that improvement takes place, and although com- 



ACUTE ASCENDING PARALYSIS. 



675 



plete recovery does occur, more frequently there remain behind disa- 
bilities and deformities, the result of permanent changes in certain 
nerves and muscles, especially of the leg and foot. 

Diag'llOSis. — The disease with which chronic anterior poliomyelitis 
is most apt to be confounded is progressive muscular atrophy, but the 
distinction between them is made by reference to the mode of onset, 
progress, and termination. The latter begins silently without systemic 
disturbance. The paralysis follows the atrophy in the latter, while in 
the former precedes it. The electrical condition of the wasted mus- 
cles is different ; in progressive muscular atrophy the muscles react 
until far advanced in degeneration, but in chronic anterior poliomyeli- 
tis the reactions of degeneration appear soon after the paralysis oc- 
curs. In respect to rate of progress, duration, and mortality, progres- 
sive muscular atrophy differs widely from the other, in that it is slower 
in progress, much longer continued, and is fatal, whereas chronic polio- 
myelitis anterior frequently gets well. 

Treatment. — The reader is referred to the section on acute ante- 
rior poliomyelitis for the method of treatment, which is as applicable 
to this disease. 



ACUTE ASCENDING PARALYSIS— LANDRY'S DISEASE. 

Definition.— This disease, as its name implies, is an acute motor 
paralysis, usually ascending, and involving all parts of the voluntary 
muscular system, with wasting of the affected muscles, but without 
change in the electrical reactions. It is entitled " Landry's Disease," 
because he first accurately described and differentiated it, although it 
had been observed before. 

Pathogeny and Symptoms. — After exposure to cold, or in conse- 
quence of alcoholic excess, or because of the presence of metals in the 
system, or excited by some unknown cause, the patient, who is usually 
between twenty and forty years of age, is seized with a little fever, 
pains in the back and limbs, numbness, tingling, and a sense of extreme 
fatigue. These symptoms continue a few days — rarely several weeks ; 
next come on extreme weakness of the feet, then of the legs, of the 
thighs, until in a few days there is complete paralysis of the lower 
extremities ; the muscles are completely relaxed, and the legs lie inert 
wherever placed. It is very distinctly an acute ascending paralysis — 
for no sooner is the loss of power in the inferior extremities completed 
than the muscles of the trunk are invaded, and, even before the abdomi- 
nal, the upper extremities become paralyzed, and, like the lower, lie 
relaxed and motionless— first, the hand in its complicated motions, 
then the forearm, and ultimately the arm and shoulder. 

Not all cases are paralyzed in the order above described, and none 



676 



DISEASES OF THE NERVOUS SYSTEM. 



are affected in strictly anatomical order — for in some few instances 
the paralysis begins in the hand and thence descends to the lower 
limbs, and in all cases the hands and feet are implicated before the 
parts most nearly connected with the spinal cord. Rarely a case oc- 
curs in which the medulla is first attacked, with the characteristic respi- 
ratory and circulatory disturbances resulting. According to Landry, 
the order in which the paralysis extends in the muscular system is the 
following : the toes and feet with the muscles acting on them ; then 
the thigh and pelvic muscles, posteriorly, and, after these, the muscles 
in the front part of the thigh. A similar order is pursued in the upper 
extremity : first are affected the muscles acting on the fingers and 
hand ; next those which move the arm on the scapula, and then those 
moving the forearm on the arm. Entirely after the muscles of the ex- 
tremities, the trunk muscles are paralyzed ; then come the muscles 
engaged in the respiratory movements, and after these, and in the 
order named, the muscles of the tongue, pharynx, and oesophagus. 
Attention to the mode in which the paralytic phenomena are devel- 
oped will facilitate the diagnosis. 

Sensibility is somewhat affected in many cases. There are numb- 
ness, tingling, formication, and impaired tactile and pain-sense, usually 
in the inferior extremities, but elsewhere the aesthesiometer discloses 
no changes. The reflexes are, as a rule, finally abolished, although at 
first there may be no change. The " knee-jerk " ceases. The blad- 
der and rectum are not affected. 

Whether the medulla oblongata be early or late affected, in every 
fatal case it is invaded by the morbid process, and its injury is the 
cause of death by asphyxia. The disease is of short duration for the 
most part, death occurring in a few days, or in a few weeks certainly, 
the average being ten days. It is not always fatal. The progress of 
the disease in favorable cases is arrested before the medulla oblon- 
gata is reached, although some cases presenting evidences of the func- 
tional derangement of this organ have, nevertheless, terminated in 
recovery. AVhen improvement does take place, the change is early 
manifested by a cessation of morbid activity, by a return of func- 
tion to the parts last paralyzed — the hands coming into use, then the 
arras, muscles of the chest, and abdomen, and finally of the lower ex- 
tremities. 

The rapid progress made by this affection, the preservation of the 
electric excitability of the muscles and of the functions of the rectum 
and bladder, the absence of bed-sores, and the prompt extension from 
below to the medulla oblongata, separate acute ascending paralysis from 
other acute affections of the cord, and render its diagnosis compara- 
tively easy after the full development of the symptoms. 

The prognosis, although grave, is not necessarily fatal. About one 
half of the cases, apparently, get well. 



MULTIPLE SCLEROSIS OF THE BRAIN AND CORD. 



677 



Treatment. — As some kind of toxic agency is supposed to underlie 
the morbid process, remedies should be addressed to the elimination 
of the poison. Syphilis, the minerals, will require large doses of the 
iodides. The rheumatic diathesis will need the remedies appropriate 
to that state. When the disease succeeds to some infection, as variola 
or typhoid, only the general condition can be taken into account. Gal- 
vanization of the cord has been apparently of benefit in a few instances. 
It is probable that the subcutaneous injection of strychnine would do 
good. It should be tried cautiously, and, if it act favorably, should 
be pushed, for, in the absence of specific lesions, a loss of power to 
functionate seems to be the essential condition of the spinal cord. 



SOME DISEASES AFFECTHSTG THE BRAIISr AND 
SPINAL CORD. 



MULTIPLE SCLEROSIS OF THE BRAIN AND CORD. 

Definition. — By the term multiple sclerosis of the brain and cord is 
meant a disease characterized by the formation of isolated patches or 
nodules of sclerotic tissue in the brain, pons, medulla, cerebellum, and 
spinal cord. It is sometimes treated of as cerebral sclerosis and spinal 
sclerosis, but it becomes more and more apparent that neither organ 
is separately affected. By Charcot* it is entitled "disseminated 
sclerosis." 

Causes. — In this disease both sexes are about equally affected, and 
it occurs from youth to middle age, becoming very rare after forty-five 
and before ten. The most powerful predisposing cause is heredity. 
Exposure to cold and fatigue, living in damp habitations, and sudden 
exposure of the body to cold and dampness when in a warm and per- 
spiring state, are alleged to be causes, but doubts may well exist as to 
their influence unless a predisposition exist. Powerful and prolonged 
moral emotion, chagrin, anxiety, and other depressing moral causes, 
may favor the development of this affection. It occurs in the conva- 
lescence from acute infectious diseases. 

Pathological Anatomy. — The disease in the brain and cord, to the 
naked eye, appear as glistening nodules underneath the pia. They 
are distinctly circumscribed, grayish patches, raised a little above the 

* "Diseases of the Nervous System," "Sydenham Society Translation," lecture ^ 
vi, p. 157. 



678 



DISEASES OF THE NERVOUS SYSTEM. 



level of the cord sometimes, or depressed below, or on a level with the 
general surface, but always perfectly defined from the adjacent tissue. 
The patches are somewhat gelatinous and translucent, and marked by 
fine white lines, round or elliptical or irregular in shape, somewhat 
closely arranged, often confluent ; dense, tough, almost cartilaginous 
in hardness ; on section, rather glistening. The nodules vary greatly 
in size, from minute, microscopic objects up to the size of a walnut ; 
in the brain they enlarge laterally ; in the cord, in its long diameter. 
They vary greatly in number as in size, and are distributed widely 
through the brain and cord. In the brain they are found not in the 
gray but the white matter — in the white matter of the hemispheres, 
ventricles, optic thalamus, corpus striatum, peduncles, pons, cerebel- 
lum ; in the cord, the nodules are found both in the gray and white 
matter and in the columns. The deposits occur in the nerve-roots and 
the nerve- trunks just as in the nerve-centers. The nodules them- 
selves are composed of the neuroglia, much hypertrophied, a newly 
formed fibrillated connective tissue, remains of the nerve-elements, 
fat- and granule-cells, and corpora amylacea. In the nerve-fibers, 
the medullary sheath is first encroached on by the hyperplasia of the 
neuroglia, disappears by absorption, leaving the axis-cylinder, which 
in turn undergoes the sclerotic change, then disappears, so that ulti- 
mately nothing remains but the newly formed fibrous tissue contain- 
ing numbers of so-called " spider-cells," free nuclei, corpora amylacea, 
and fat. Similar changes occur in the walls of the vessels, beginning 
in the adventitia and in the perivascular lymph-spaces. Ultimately 
the adventitia is closely united to the surrounding connective tissue, 
the other tunics are invaded by the hypertrophied connective tissue, 
nuclei form in great numbers, fatty degeneration occurs, the fat-ele- 
ments crowding the perivascular lymph-spaces, and encroaching on 
the lumen of the vessels. 

Symptoms. — There are three forms usually described : the cerebral, 
the spinal, and the cerebro-spinal. But the description of this disease 
was purposely postponed to this point, as the spinal and cerebral forms 
rarely, if ever, exist separately, but the disease is cerebro-spinal scle- 
rosis, in which, it is true, there may be a predominance of the cerebral 
or of the spinal symptoms in different cases, but in all the traces of 
both are discernible. 

There are two modes of onset — a gradual and insidious mode, and 
a sudden and severe mode. When it begins slowly the symptoms 
may be chiefly cerebral or chiefly spinal : in the former, headache, 
vertigo, convulsions, or an attack of an apoplectiform variety, disor- 
dered and staggering gait, tremors in certain limbs or groups of mus- 
cles, impairment of special senses — of sight, of taste, of hearing, dou- 
ble vision, etc. ; imperfect speech, and mental disorders of various 
kinds ; in the latter (spinal form) there will be weakness and uncer- 



MULTIPLE SCLEROSIS OF THE BRAIN AND CORD. 



679 



tainty of gait, ataxic disorders, numbness^ tingling and pains in the 
extremities, incoordinate movements in writing, trembling, and severe 
attacks of gastralgia. This disease, as Charcot happily said, " is, in 
fact, an eminently polymorphic affection."* In the sphere of the 
sensory nervous system there are pains of various kinds, according to 
the position of the sclerotic nodules ; pains in the face in the distribu- 
tion of the fifth nerve, in the arms, and in the lower limbs, of an 
acute, lancinating character, with more diffused pains with a sense of 
pressure, constricting or girdle pain around the abdomen at different 
heights, with pains in the back and hips. Instead of pain, there is 
at a more advanced stage loss of sensation in various parts, or anaes- 
thesia and analgesia. The sense of the position of members and of 
weight and resistance is also disordered or lost. There may be an 
entire absence of these sensations, and the appreciation of touch and 
pain continue normal. The disturbances in the motor sphere are more 
constant ; first, motor weakness or paresis, which attacks one leg, then 
the other, and after a time the arms, or the order may be reversed ; 
difiiculty of locomotion, due not only to paralysis but to tonic con- 
traction — the contraction of extension — which imparts to the gait a 
shuflling, dog-trot, or titubating character. The tonic contraction of 
extension passes into permanent contractures and rigidity. In many 
cases in which sclerosed nodules are largely deposited in the posterior 
columns the gait is incoordinate, and the usual phenomena of ataxia 
(reeling with the eyes closed, the peculiar gait) are present. Similar 
changes occur in the upper extremity, but the contractures and paraly- 
ses are usually hardly so pronounced as in the lower extremities. A 
very characteristic symptom is tremor, a shaking tremor, which occurs 
only during voluntary movement, and ceases when the parts are at 
rest. In the words of M. Charcot, " the tremor manifests itself on the 
occasion of intentional movements of some extent ; it ceases to exist 
when the muscles are abandoned to complete reposeP Exceptional 
cases are encountered in which tremor is not present. It may have 
been present and then disappeared ; it ceases when permanent con- 
tractions occur, so that the case can not be regarded as exceptional if 
the tremor is found on inquiry to have been present at some previous 
time and is now absent. The more powerfully the will is directed to 
the act, the more considerable and extensive the trembling. In con- 
veying a glass of water to the mouth, the water is spilled and the glass 
rattles against the teeth. In any muscular act to which the attention 
is strongly attracted, not only the member acting, but the head, neck, 
and body are thrown into violent trembling. The reflexes are vari- 
ously affected, and may be diminished or absent, but are often greatly 
increased, especially the tendon reflexes. Vesical, sexual, and rectal 



* Supra, p. 183. 



680 



DISEASES OF THE NERVOUS SYSTEM. 



disturbances only appear toward tlie end, when incontinence, impo- 
tence, and constipation will come on. While these symptoms from 
the spinal lesions are developing, characteristic cerebral phenomena 
also are occurring. The psychical functions are disordered. At first, 
changes of disposition are noticed, the emotional centers becoming 
easily excited, and laughing and weeping occurring with equal readi- 
ness ; irritability of temper and unexpected gusts of anger are com- 
mon. Memory is early impaired, and reason, judgment, and the 
power to acquire knowledge are much weakened. Presently distinct 
forms of mental derangement make their appearance, as melancholia, 
mania with exaltation, and finally dementia. During the course of 
development of the psychical symptoms, vertigo, severe headache, and 
attacks of obstinate wakefulness appear, and there are also now and 
then apoplectiform attacks, followed by hemiplegia. Peculiar altera^ 
tions occur in the speech and voice. The speech has the slow, jerking 
movement as in scanning, and becomes less and less distinct. The 
tongue and lips and the muscles of the palate and pharynx become 
paretic, and hence mastication and swallowing are difficult. The ocu- 
lar muscles being similarly affected, there are diplopia, or double vis- 
ion, nystagmus, and amblyopia, proceeding ultimately to amaurosis. 

Course, Duration, and Termination. — Not all cases pursue the typi- 
cal course just described. The cerebral symptoms may be in excess, 
and the spinal less pronounced (cerebral sclerosis) and vice versa (spinal 
sclerosis). As Erb has well said, "the correctness of this division has 
not, however, been demonstrated with satisfactory clearness." Char- 
cot has divided the disease into three parts (p. 210) : the first extend- 
ing from the inception to the permanent contractures — -a period of 
very variable duration, but lasting from two to six years ; the second 
period, in which the motor functions are almost abolished, the mind 
disordered, but the nutrition continues good, in which the individual 
is reduced to a merely vegetative existence, continues not less than 
four and often more than six years ; the third period is comparatively 
brief, in which nutrition fails, digestion becomes disordered, swallow- 
ing increasingly difficult, cystitis arises from paralysis of the bladder, 
bed-sores form, respiration and circulation become irregular and dis- 
ordered, by reason of extension of the sclerosis to the medulla, apo- 
plectic attacks occur, and not unfrequently some intercurrent disease 
appears. The whole duration of the disease varies from one or two 
years to twenty, but the average is five to ten years. The termination 
may be by exhaustion or by apoplexy, but usually some pulmonary 
disease ends life. The termination by death is the only one known. 
Sometimes remissions occur that are very illusory. 

Diagnosis. — The fully developed disease is so remarkable, by reason 
of the multiplicity of the symptoms, that a diagnosis is made without 
difficulty. But in the partial cases there may be much difficulty. Cere- 



DEMENTIA PARALYTICA. 



681 



bro-spinal sclerosis is often confounded with paralysis agitans. The 
former occurs in youth and early manhood, the latter in old age ; the 
former is accompanied by tremors that do not occur when the patient 
is at rest, and increase by volitional effort ; the latter by tremors that 
continue during rest, and that are lessened by an effort of the will. 
In the former, paresis or paralysis precedes tremor ; in the latter, suc- 
ceeds, and long after. In the former, peculiar defects of speech, of 
vision, of motility, etc., occur ; in the latter not. Cerebro-spinal scle- 
rosis may be confounded with locomotor ataxia, as in both there are 
ataxic disorders. In the former, there are mental disorders, paralysis, 
contractures, tremor, troubles of speech, and preserved and increased 
tendon reflexes ; in the latter, none of these, and ataxia without paraly- 
ses or contractures, pains, peculiar sexual disorders, and no tendon 
reflexes. 

Treatment. — Several remedies have appeared to act beneficially, 
although no cures have occurred. " Marked improvement set in under 
the use of subcutaneous injections of arsenic," says Erb, in one case. 
The galvanic current has appeared to benefit in a few instances. In 
other cases good results, if temporary, have been produced by nitrate 
of silver. Hammond thinks the chloride of barium does good. The 
most promising treatment is the combined use of galvanism, cold 
hydrotherapeutic applications, carefully made, cod-liver oil and nitrate 
of silver ; but still more useful, according to the author's experience, is 
the chloride of gold and sodium, and with this may be advantageously 
given, for a time, corrosive sublimate in minute doses. 

DEMENTIA PARALYTICA— PROGRESSIVE GENERAL PARALY- 
SIS. 

Definition. — By dementia paralytica is meant an atrophic change 
in the brain characterized by a peculiar form of mental derangement, 
associated with general paralysis. 

Causes. — The cases largely preponderate in the male sex, the dis- 
proportion being nearly four to one. The most active and vigorous 
period in life — from twenty-five to forty-five — is the period for the 
appearance of this disease. Heredity seems to be an important cause^ 
but the data do not exist for an exact statement. Excesses — the com- 
bined effect of overwork, alcoholic abuse, and venereal indulgence — 
are the most influential of all factors operating to produce the disease. 

Pathological Anatomy. — A diminution in the weight and volume 
of the brain, due to an atrophy of its gray and white substance, is the 
characteristic alteration in this disease. The pia mater is (edematous, 
generally, or in the sulci, and a good deal of water is found between 
the parietal and occipital lobes ; the ventricles, especially the cornua, 
are dilated, the ependyma thickened and roughened by granular depo- 
Bition ; the convolutions are shrunken, particularly those of the poste- 



682 



DISEASES OF THE NERVOUS SYSTEM. 



rior lobes, and the white and gray matter thinned and atrophic. The 
pia mater is greatly changed in structure, especially in the neighborhood 
of the vessels, and thickened by spots and patches of exudation of a 
yellowish color, and is readily stripped from the brain-substance. The 
dura mater is also much altered, closely united to the skull, thickened 
by exudations, and sometimes covered by a sanguineous extravasation. 
A peculiar change takes place in the vessels, of w^hich the initial alter- 
ation is an increase of the nuclei in their tunics, and filling of the 
perivascular lymph-spaces with white and red corpuscles. The walls 
of the vessels become fatty or undergo the colloid degeneration. The 
ganglion-cells of the gray matter pass through atrophic changes, re- 
sulting in their final destruction. The membranes of the spinal cord 
undergo similar changes to the cerebral, but less frequently. Impor- 
tant alterations take place in the spinal cord ; gelatiniform degenera- 
tion, with entire disappearance of the proper anatomical elements, is 
the final result. The posterior columns are altered throughout their 
whole extent in the dorsal and lumbar portion, but in the cervical 
the change is chiefly in Goll's columns. Another kind of change 
which takes place in the postero-lateral columns is a granular mye- 
litis, followed by hyperplasia of the connective tissue. Both kinds of 
change may exist together. The granular myelitis is not limited to 
the cord proper, but extends to the medulla, pons, and crura cerebri. 
The posterior roots are affected with the posterior columns, but the 
peripheral nerves are seldom diseased. 

Symptoms. — The symptoms of this disease are naturally divisible 
into two groups — mental and motor derangements. A correct appre- 
ciation of the mental phenomena in these cases is of the highest im- 
portance, owing to the serious complications often arising out of the 
conduct of these subjects. The motor disturbances may precede, but 
they more usually follow, the first evidences of mental aberration. 
Changes in the character, disposition, and habits, and irritability and 
a quarrelsome disposition, quite at variance wdth the previous charac- 
ter, become manifest. Headache, transient vertigo, and inequality of the 
pupils, are among the early symptoms. It is observed that they fail in 
memory, especially of recent events ; they are absent-minded and talk 
to themselves. Some trembling of the lips may be seen, as well as of 
the muscles of the face and of the tongue. The speech becomes thick 
and rather guttural and is hesitating, and at the same time the voice 
is changed : it is nasal, and has assumed a different quality, the tenor 
voice becoming bass. Owing to the paresis and fibrillary trembling 
of the muscles of the tongue, and paresis of the muscles of the lips, 
the labials are pronounced with difficulty or slurred over. They early 
have expansive ideas and most deluded notions of what they can ac- 
complish. Before their mental unsoundness is patent, they make pur- 
chases, or engage in ruinous enterprises, always on a large scale, and 



DEMENTIA PARALYTICA. 



683 



they often exhibit a marvelous ingenuity in accounting for their acts. 
Hence the frequent litigation growing out of the acts of such paralyt- 
ics before their real condition is known. After a time their ideas be- 
come so extravagant that the least informed can understand their state. 
Such a man has written an immortal work, or made a great invention, 
will build a house many miles high, will run a railroad to the moon, 
possesses countless wealth, is a king, has astonishing personal prowess, 
has the strength of a thousand men, etc. So quick is he to forget his 
statements that, if exposed in an absurdity, he immediately reaffirms it 
in a still stronger form. He is therefore perfectly happy in the midst 
of his delusions of personal importance. Meanwhile he has become 
indifferent to all the obligations and duties of life, ceases to have any 
affection for the members of his family, or cares for one only, pays no 
attention to his affairs, and steals, without a thought of the offense. 
Not all cases present the evidence of exaltation of ideas and happi- 
ness from a false conception of personal importance and well-being. 
Some are dejected and melancholy, but the ideas of depression have 
corresponding vastness, and their misfortunes are the greatest the 
world has ever seen. During the course of development of the men- 
tal symptoms, some of these subjects are given to paroxysms of rage 
as blind and ungovernable as those of an epileptic. Enraged by the 
least opposition, or excited by some trivial incident, they will commit 
a murderous assault on their best friends, and this, too, stealthily and 
without warning. During this state there is wild excitement like 
acute mania. This condition of excitement may persist until death 
by maniacal exhaustion, or it may pass into the condition of dementia. 
As these attacks of excitement are accompanied by elevated tempera- 
ture, it is probable they are induced by chronic meningitis, traces of 
which are always seen in the anatomical changes. The ideas of exal- 
tation and of melancholy often are present in the same case, and alter- 
nate, the patient passing quickly from one to the other. Delusions 
are not always present. There may be a gradual and progressive fail- 
ure of intelligence to dementia, without there being any delusion, 
unless the expansive notions, which are apt to appear some time, are 
so regarded. A very characteristic mental state is the unconscious- 
ness of weakness and of disease exhibited by these subjects, unless, 
as may happen during a remission, the patient recovers sufficient mem- 
ory and judgment to appreciate his changed state. During the height 
of the symptoms, although paralyzed, he has the strength of a giant, 
and, though suffering from ailments which in the ordinary state of the 
mind cause great distress, he experiences nothing but an extravagant 
sense of well-being. In the motor sphere very important symptoms 
arise. Disorders of coordination begin in the inferior extremities — 
an ataxic gait, reeling on closing the eyes, etc., and after a time extend 
to the superior extremities. Early the handwriting assumes an irregu- 



684 



DISEASES OF THE NERVOUS SYSTEM. 



lar, trembling, jerking character, and at length becomes impossible. 
The resemblance to locomotor ataxia is all the stronger, since there 
may be ocular troubles, double vision, amblyopia, and even amaurosis, 
altered sensations, anesthetic tracts, etc., about the body, and reten- 
tion or incontinence of urine and faeces. These locomotor ataxia symp- 
toms, we may assume with propriety, result from the sclerotic nodules 
deposited in the posterior columns, but a granular myelitis attacks the 
lateral columns in a smaller proportion of cases, when there will occur 
the peculiar shuffling and helpless gait and the anaesthesia belonging 
to this lesion. A paretic, ultimately paralytic state of the facial nerve 
occurs in many cases, and the muscular system generally is thus af- 
fected. Hemiplegia, usually transient as regards the motor functions, 
is often the result of an apoplectic seizure which may inaugurate the 
symptoms, or occur at any period during the course of the disease. 
Instead of motor hemiplegia, sensory hemiplegia may result from a 
sudden attack with loss of consciousness. Although such motor and 
sensory symptoms disappear very quickly, the mental condition is 
always much injured by these attacks. During the course of the dis- 
ease, epileptiform seizures also occur ; they may be unilateral or gen- 
eral, severe or mild. Epilepsia mitior, petit mal, with loss of conscious- 
ness, but no convulsive phenomena, may be substituted for the severe 
attacks or occur with them. Death may happen in the coma which 
follows an attack, or a decided remission in the symptoms, with appar- 
ent improvement in the mental state, may occur. 

Course, Duration, and Termination. — Dementia paralytica is a chron- 
ic disease, but its duration can not be fixed very accurately, owing to 
the uncertainty which attends the time of the initial symptoms. It may 
be said that the cases vary in duration from one to ten years. It is 
true, deaths have been reported as occurring within a year, or in a few 
months, but there must be doubts in regard to the diagnosis in such 
cases. When the disease begins by apoplectic phenomena, the prog- 
ress may be more rapid ; and, when such attacks occur during the 
height of the malady, the progress downward is accelerated, although 
the injury caused by the apoplexy is largely recovered from. The 
usual course is a gradual increase in the paresis ; the countenance be- 
comes more blank, expressionless, and the muscles more relaxed ; irreg- 
ular jactitations occur in the facial muscles whenever speech is at- 
tempted or emotions are felt ; the mode of speech becomes more and 
more stammering, and, as the memory becomes more and more de- 
ficient, words are omitted so extensively that the speech is unintelli- 
gible. The voluntary efi^orts are so enfeebled that no movements can 
be undertaken, and hence the patient sits motionless, or is finally bed- 
ridden, passing his urine and faeces involuntarily. Toward the end the 
nutrition fails, the body wastes, and an extreme emaciation is the 
result ; rarely the face is full and flabby, the abdomen prominent. 



DEMENTIA PARALYTICA. 



685 



The tongue becomes more and more paretic, swallowing increasingly 
difficult, and particles of food drop into the larynx, exciting suffocative 
attacks. Death may be caused by a pneumonia thus excited, or may 
occur by an apoplectic seizure, or in the coma succeeding a fit, or may 
be due to the exhaustion resulting from bed-sores. A considerable 
proportion are carried off by phthisis. It occasionally happens that a 
remarkable remission takes place in the condition of the general para- 
lytic when it seems hopeless. The speech improves, the paresis of the 
muscular system disappears, and normal strength is restored, reason 
and judgment return again, and hallucinations and illusions no longer 
occur. This remission may last a short time, the disease revive, and 
the progress into its worst phases be again very rapid. On the 
other hand, the remission may pass on to complete restoration, the 
patient being restored to his friends and his work in life. This for- 
tunate result is extremely uncommon, but has occurred often enough 
to require the utmost circumspection in giving an opinion. Except 
these cases, there is little to encourage in the course and results of this 
melancholy disease. 

Diagnosis. — The differentiation of dementia paralytica is easily de- 
cided when the symptomatology is complete. The expansive ideas, 
the paralysis, the failure of memory, the lack of all moral feelings, suf- 
ficiently indicate the nature of the malady ; but the cases not fully de- 
veloped may be recognized with difficulty. The defects of speech, of 
intelligence, and the existence of paralyses with ataxic symptoms, 
serve to distinguish dementia paralytica from posterior spinal sclero- 
sis. From senile dementia the differentiation is made by reference to 
the expansive ideas, the moral state, the peculiar affection of speech, 
the existence of ataxia and paralyses, and the age at which the phe- 
nomena became manifest. 

Treatment. — Above all other cases, if we except acute mania, and 
the suicidal, there are none needing more the restraint of asylum 
treatment. In the attempt to put them into the asylum early, serious 
difficulties are encountered ; for they are very plausible, and easily 
obtain legal assistance. Above all things, these subjects require rest, 
both of body and mind, and careful alimentation. The most suitable 
remedies are lactophosphate of lime and cod-liver oil, with quinine and 
morphine, to improve the nutrition of the brain and to obtain repose 
at night. To quiet restlessness and procure sleep, hyoscyamine (^^ 
to yV grain) has been used with excellent effect hypodermatically. 
Chloral and morphine are often indispensable for this purpose, and in 
considerable doses. Entire rest, sufficient sleep, and a nutritious and 
careful alimentation, offer the best prospects of affording relief in 
this disease. Good results, of a temporary character, have been ob- 
tained from physostigma, and lately Ginna reports that full dose-s 
of ergot have proved remarkably effective ; but it is obvious that 



686 



DISEASES OF THE NERVOUS SYSTEM. 



only in an early stage of the disease could any real improvement be 
accomplished. 

SYPHILIS OF THE NERVOUS SYSTEM. 

Definition. — By syphilis of the nervous system is meant deposits of 
tlie secondary and tertiary stages, so called, in the meninges, in the 
substance of the brain and cord, and in the peripheral nerves. 

Causes. — The nervous system is affected coincidently with the 
other viscera. The disease, pursuing its regular course, attacks the 
skin and mucous membrane, then the deeper organs and tissues. There 
is no fixed period for the appearance of syphilitic deposits in the nerv- 
ous system. Susceptibility increases the rate of diffusion of the poi- 
son, and as there may be variations in its intensity, so there may be 
considerable differences in the time when the viscera are reached. It 
may be stated, in general, that the infection of the nervous system 
takes place during the later secondary or early tertiary period — in from 
one to three years usually ; but it may occur within one year, or be 
postponed twenty years. In a large number of cases — the author has 
seen several — the nervous is the only secondary affection ; but usually 
other lesions have existed, and in one third relapses have occurred. 
The disposition of syphilis to attack a particular part may be deter- 
mined by existing injury or disease, or hereditary or acquired tend- 
ency to disease ; and this is true of syphilis of the nervous system. All 
the causes, therefore, that tend to bring about disorders in the nerv- 
ous system will determine attacks of syphiloma. 

CEREBRAL SYPHILIS. 

Pathological Anatomy. — The syphilitic masses, known as gummata, 
form in the subarachnoid space, or on the inner surface of the dura, 
and grow toward the brain. There is also a syphilitic pachymenin- 
gitis, which occurs at the convex surface of the hemispheres, especial- 
ly forward on the anterior lobes, and in the middle fossa about the 
sella turcica. It is the external form, and is usually associated with 
bony lesions, and with the two forms of gummata. These, springing 
from the inner surface of the dura and from the subarachnoid space, 
are the most important of the syphilitic new formations. The first 
variety of gummata consists of a soft, reddish, translucent mass, com- 
posed of round cells and nuclei, spindle and stellate cells, distributed 
through the tissue of the part ; and hence the density of the result- 
ing mass is determined by the character of the tissue in which these 
cells are deposited. A number of cells may be closely packed in a 
considerable interspace, forming an alveolar arrangement, or, exuded 
into a reticulated tissue, will have a corresponding appearance. The 
new tissue contains capillary blood-vessels, and there may be extrava- 



CEREBRAL SYPEILIS. 



687 



sations by their rupture. This form is not separated by a sharp boun- 
dary from the normal tissue, but the cells push out into their surround- 
ings. The other form of gumma is not so soft and translucent, but 
is dry, firm, and yellowish, so that it is sometimes said to be fatty, 
but is really a cheesy transformation. They exist in two forms : as a 
diffuse infiltration, and in circumscribed, well-defined masses, varying 
in size from a pea to a pigeon's -egg. A favorite site of this gumma is 
inclosed between the two layers of the dura, where it may attain 
considerable size. When the gummata form at the convexity, it is 
found that the granulation-tissue has completely united and blended 
the membranes, so that they are not distinguishable. Here the yellow 
masses may lie imbedded in the grayish-red gumma, and about the 
mass, the brain-substance into which the neoplasm projects, is in a 
state of white or red softening. At the base the gummata, developing, 
fill in all the interstices around the chiasm, the crura, and the pons. 
Here the grayish-red growth is chiefly seen. By developing into the 
adjacent brain-substance, it causes softening. A syphilitic new for- 
mation also occurs in the vessels of the base. The affected vessel is 
thickened, grayish, and hard, by the deposits which form a cylinder ; 
the lumen of the vessel is encroached on, so that it transmits only 
one half or one fourth the usual quantity of blood. When this change 
occurs in several of the vessels, the cerebral circulation is much em- 
barrassed. It will suffice to say that the changes consist in the forma- 
tion of granulation-tissue in the tunics of the vessel, the morbid pro- 
cess beginning in the intima. Besides the gummata, the meninges may 
be affected by a syphilitic inflammation, which consists in the forma- 
tion of thick and rather tough patches, which do not differ in struc- 
ture from the gummata. Inflammation may also take place in the 
brain-substance, and terminate in softening. 

Symptoms. — The first symptom is headache ; it is usually very se- 
vere, and has this peculiarity, that it is much worse at night, and may 
indeed be felt only at night. The pain may disappear spontaneously, 
to return again, sometimes after a brief and sometimes after a long 
interval, but is usually continuous ; * it is increased by a slight tap on 
the head, and its position may indicate the seat of the lesion (Lance- 
reaux). The severe nocturnal pain causes wakefulness, but this symp- 
tom may be present when there is no pain. Vertigo, confusion of 
mind, irritability, iu ability to apply the mind to any subject, and mel- 
ancholy, with suicidal feelings, are symptoms experienced with more or 
less severity from the time when the new formations begin to develop, 
and may be due to congestion as supposed by Lancereaux, but also to 
compression of the intra-cranial contents. After a time, fainting-at- 
tacks occur without any special cause ; weakness is experienced in the 



* Lancereaux, "Treatise on Syphilis," Sydenham Society edition, vol. xi, p. 46. 



688 



DISEASES OF THE NERVOUS SYSTEM. 



legs, which give way unexpectedly ; there may be defects of speech 
from inability to articulate ; loss of the memory for words, exceed- 
ing slowness of speech ; dimness of vision (amblyopia), with double 
vision, unequal pupils, strabismus, the ophthalmoscopic examination 
showing swollen disks, distended and tortuous vessels, etc. ; noises in 
the ears and dullness of hearing ; there may be maniacal symptoms, 
but more frequently the kind of mental defects mentioned above ; epi- 
leptiform attacks succeeding to the fainting, and they may be partial, 
limited to one extremity, without loss of consciousness, or general, with 
unconsciousness. There may be, and usually are in basal deposits, 
especially those situated in the middle fossa, the usual site, defects 
of coordination, unstable gait, excessive vertigo, nausea, and vomiting, 
rapid impairment of vision, swollen eyelids, bleeding at the nose, etc. 
There are other motor defects, besides the impaired coordination and 
reeling gait : paresis of the muscles of one side, including the face, 
coming on slowly without an apoplectic seizure ; there may be a mere 
weakness of one extremity, dragging of the foot a little, inefficient use 
of an arm, but still preservation of its motions, or it may be limited to 
one side of the face. In many cases there are, besides the motor dis- 
orders, bilateral affections of sensibility ; there may be neuralgia (tic- 
douloureux or sciatica), but more frequently the sensations are depressed 
— there are extensive tracts on both sides, of complete loss of the sense 
of pain (analgesia) and of the sense of touch (anaesthesia), which, again, 
in other cases, may be more or less perfectly preserved. 

There is another group of cases in which, preceded by the symp- 
toms which announce the growth of the new formations, but which 
may, however, be not very decided in their manifestation, there occur 
sudden apoplectic seizures, varying in severity from profound uncon- 
sciousness to a momentary dazed feeling, after which a hemiplegia is 
found to exist (Huebner). These attacks with the resulting lesions 
may proceed in the usual way of a hemiplegia from intracranial 
haemorrhage or other lesion, of course very much influenced by the 
treatment, but in a certain proportion of the cases they lie in a somno- 
lent or partly somnolent condition, from which they may be awakened, 
but at once lapse back. These attacks are usually preceded by head- 
ache, by a feeling of exhaustion, and by a stupid, inactive mental state, 
which may pass slowly into the condition of somnolence. During this 
state, acts are performed like those of a somnambulist, as in getting up 
to urinate, etc. ; and when roused they awaken, gaping and yawning, 
but coherent, yet soon lapse back into stupor, with an air of protest 
at having been disturbed. These periods of somnolence vary in du- 
ration ; usually continue from night to the following afternoon, and, 
as in a case lately seen by the author, the usual times of sleep are 
disturbed by severe nocturnal headache. Often, but not always, 
these somnolent periods are accompanied by fever of a remittent 

l; 

I 



SPINAL SYPHILIS. 



689 



type. The somnolent period may last a few days, even several weeks, 
and may proceed to deeper coma ending in death, or the stupor may 
grow less dense, the intervals of wakefulness longer, and ultimately 
the somnolence disappears entirely. Cerebral syphiloma manifests 
itself by still another group of symptoms, namely, those of dementia 
paralytica. It begins with various symptoms of irritation in the in- 
tellectual sphere — confusion of mind, irritability, melancholy of an 
expansive kind, and ideas of grandeur. These symptoms may appear 
and disappear, and long intervals elapse, until at length symptoms of 
weakness come on, with such abnormal sensations as numbness, tin- 
gling, and formication, followed by inability for any considerable exer- 
tion, incoordination of movements, paralyses. The mental condition 
ultimately is that of dementia. 

Course, Duration, and Termination. — There are no maladies in 
which the results of treatment are more conspicuous for good, and 
which are more influenced in their course, duration, and termination. 
The second form of Huebner, characterized by the apoplectic phenom- 
ena, followed by hemiplegia, is the shortest in duration, the lesions 
being chiefly in the vessels. Even if a cure does not take place, im- 
provement may be effected, and the duration not be less than four 
years. In the second form, the opportunities for successful treatment 
are numerous, and the results under an appropriate medication very 
striking. Without treatment, weeks and months may pass before the 
final result is reached. The form, so like dementia paralytica, is more 
protracted, is subject to great fluctuations, and may continue for sev- 
eral years. Notwithstanding the curability of many cases — those, for 
example, with hemiplegia, or local paralyses, and with repeated epi- 
leptiform seizures — yet many cases resist the best-directed efforts, and 
for reasons that are obvious : the gummata, by pressure, produce soft- 
ening and destruction of nerve-tissue, which can not be replaced. 
Furthermore, syphilitic cerebral affections manifest a great tendency 
to relapse after apparent cure. 

SPINAL SYPHILIS. 

Pathological Anatomy. — As in the brain, gummata spring from the 
internal surface of the dura, grow into the nervous matter, and unite 
the membranes in a compact mass. They have the structural pecu- 
liarities of gummata in the brain and elsewhere (Moxon Softening 
of the cord is a result of the presence of these new formations ; partly 
due to pressure and partly to development inwardly of the neoplasm. 
Syphilitic disease occurs in the bones of the vertebrae, in the connective 
tissue, and in the outer layer of the dura, producing the symptoms of 
compression. 

* " On Syphilitic Disease of the Spine," " Guy's Hospital Reports," vol. xvi, 1870. 
46 



690 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms. — Long after, often many years after, the specific local 
lesion, deposits occur in the spinal canal. According to the author's ob- 
servation * the spinal troubles may be coincident with the development 
of fresh tertiary symptoms elsewhere. The most constant symptom is 
a deep-seated pain in the dorsal or lumbar region, increasing at night ; 
a pain of such severity as to require powerful anodynes to obtain suf- 
ficient relief for sleep. There may or may not be tenderness on pres- 
sure. Usually a great deal of pain is experienced in one or both of 
the sciatic nerves, and tingling, numbness, and burning sensations in 
the legs and feet. More or less weakness, a strong sense of fatigue on 
slight exertion, stiffness and cramps are experienced in the muscles of the 
spine, of the neck, and of the extremities. As the disease is develop- 
ing, the general system sympathizes to a remarkable extent ; a peculiar 
earthy hue of the face, emaciation, and debility are observed. The 
symptoms may continue at this point for a long time, or partial im- 
provement take place, and then, after some weeks or months of inac- 
tion, more serious symptoms come on. When the symptoms become 
active again, paralysis begins and proceeds with great rapidity, and 
becomes so complete that not a toe is movable. The paralysis may be 
due to disease of the dorso-lumbar enlargement, and both lower limbs 
be completely paralyzed (paraplegia) as to motion, sensation, and the 
reflexes. The sphincters will also be involved, and incontinence be 
added to the other troubles. There may be partial paralysis, one limb 
involved. When the arms are affected, there will be oculo-pupillary 
phenomena, and the respiratory muscles will be paretic or paralyzed if 
the disease is high up in the cervical region. These spinal troubles of 
syphilitic origin may be associated with corresponding cerebral lesions, 
when, of course, the symptoms will partake of both. There is a form 
of acute spinal paralysis described by Huebner which comes on during 
the first secondary symptoms, and is characterized by a sudden para- 
plegia or paralysis of one arm and the opposite leg. In a few hours, 
or a day or two, the mischief is wrought, and the paralysis complete. 

Course, Duration, and Termination. — The course of the principal 
forms of spinal lesions is very protracted, and they appear long after 
the local primary. Rightly treated they get well promptly, but, as is 
the case with the cerebral disease, they are prone to relapse, yet the 
ultimate cure is probable. When paraplegia has occurred with abso- 
lute paralysis, a cure may often be effected in a few weeks ; but that 
this favorable termination shall take place it is essential that the in- 
jury be recent. If the cord has been damaged, permanent disability 
will remain, although the disease may be arrested. Old cases may 
terminate fatally by exhaustion from cystitis and bed-sores. The 
acute form, described by Huebner, seems to be very unmanageable, 



* " Oq Syphilis of the Nervous System," " The Clinic," 1874. 



EPILEPSY. 



691 



and to reach a fatal termination by extension upward. In the spinal 
as in the cerebral form, much depends on the treatment instituted. 

SYPHILIS OF THE NERVES. 

Pathological Anatomy. — The cerebral nerves seem to be chiefly if 
not the only nerves attacked by syphilis. The deposits may be exte- 
rior, and press on the nerve-trunks, producing a neuritis, which leads to 
atrophic changes and degeneration. A gumma surrounding a nerve- 
trunk unprovided w^th a sheath will grow into the tissues of the nerve, 
and syphilitic granulation-tissue may be deposited in places, and de- 
velop in the ordinary way. 

Symptoms. — The results of such affections of nerve-trunks have a dif- 
ferent expression according to the function of the nerve. Irritation of 
a sensory nerve produces pain in its peripheral distribution ; but, if the 
nerve is destroyed, anassthesia and analgesia are experienced. On the 
other hand, if a motor nerve is irritated, spasms or tonic contraction will 
ensue in the muscles to which this nerve is distributed ; if the nerve is 
destroyed, paralysis ensues. As the cerebral nerves are usually affect- 
ed, the same symptoms result from syphilitic neoplasms as have been 
described in connection with other neoplasms or tumors of the brain. 

Diagnosis of Syphiloma of the Nervous System. — The first point to 
determine is the occurrence of syphilitic infection. The peculiarities 
of the syphilitic affections of the brain are their diffusion, the irregu- 
larity in the development of the symptoms, the simultaneous existence 
of irritation and depression, the periods of spontaneous improvement, 
the remarkable change in the condition of a patient receiving iodide 
of potassium or mercury in some form, etc. 

Treatment. — In these affections the most marvelous change is 
wrought by sufficient doses of the iodide of potassium. ISTo time is 
to be lost in its administration, and usually the largest doses are re- 
quired. Sometimes mercury does better, and lesions do not yield 
until it is administered. It has been observed, also, that cases not 
yielding readily to specific treatment, will do so on the exhibition of 
pilocarpine to promote absorption. 



CEREBRO-SPINAL NEUROSES. 



EPILEPSY. 

Definition. — By the term epilepsy^ as here employed, is meant true 
or essential epilepsy, and not eclampsia, nor convulsion from such cause 
as tumor, abscess, etc., of the brain. 



692 



DISEASES OF THE NERYOUS SYSTEM. 



Causes. — Heredity occupies the first place as an etiological factor. 
In Echeverria's * cases, about twenty-five per cent., and in Reynolds's f 
about thirty per cent, were distinctly due to hereditary transmission. 
It is a neuropathic constitution or tendency which is inherited, and this 
exhibits itself in various forms in different generations. In one gen- 
eration it is neuralgia, nervousness, paralysis ; in another, epilepsy ; in 
a third, insanity. Next to the inheritance of a neurotic tendency, in 
point of importance as a cause, is the influence of drunkenness in the 
father on the product of conception. Sexual excesses and onanism are 
held to be frequent causes, but much exaggeration has existed in re- 
gard to their effects in this way. They are more frequently the result 
than the causes of epilepsy. As regards age, the greatest number of 
cases occur in the decennary from seven to seventeen. As regards sex, 
the two are about equal in their liability to the disease. According to 
Reynolds, not one case which was hereditary began after twenty, while 
twenty-six per cent, of those not hereditary were affected after twenty. 
Irritation of peripheric nerves, dentition, and injuries to the cranium, 
are among the occasional causes. Epileptic seizures have been ex- 
cited by various psychical impressions — ^by fear, by irritation, by cha- 
grin, and other powerful emotions. 

Pathological Anatomy. — There is no morbid alteration peculiar to 
epilepsy. In this important respect true epilepsy differs from epilep- 
tiform seizures. Although there is no special change, various acci- 
dental pathological alterations are found in the cranial cavity. Changes 
in the contour and structure of the skull ; thickened, indurated, and 
calcareous meninges ; increase in weight of the brain according to 
some (Echeverria), and diminution of weight according to others ; 
changes in the hippocampus (Meynert) ; tumors of the cortex ; varia- 
tions in the distribution of the gray matter — are gross lesions which 
have been ascertained to exist in old cases of epilepsy. Long ago 
Schroeder Van der Kolk J found alterations in the medulla, consisting 
in dilatation of the arterioles and fatty degeneration of their tunics. 
Echeverria § confirmed these observations and added investigations of 
his own, to the effect that not only are the vessels enlarged, their 
tunics fatty, but that hyperplasia of the neuroglia and atrophy of the 
cells of the medulla are constant changes in epilepsy. The same author 
has ascertained the existence of sclerotic changes in the ganglia of the 
sympathetic, but the relation which such changes bear to the produc- 
tion of epilepsy is by no means clear. 

Symptoms. — The phenomena of epilepsy are exhibited in two forms? 

* " On Epilepsy," by M. Gonzales Echeverria, M. D., New York, 1870. 
f "Epilepsy," etc., by J. Russell Reynolds, 1861, p. 123. 

j On the Minute Structure and Functions of the Spinal Cord," Sydenham Society 
edition, 1859, p. 231, et seq. 
§ Op. cii., chapter xi, p. 46. 



EPILEPSY. 



693 



of seizures, and in the state of the affected individual in the inter- 
val between the convulsive or unconscious attacks. The epileptic 
seizures are : epilepsia gravior, the severer epilepsy, the epileptic 
fit, called by the French writers le grand mal, and epilepsia mitior, 
milder epilepsy, le petit mal. Adopting the classification of Jac- 
coud, we have the first form occurring in two modes — the common 
or ordinary form, and the apoplectic y the second also in two — ver- 
tigo and absence. Many cases of the common form begin without 
any indication of their approach, but a certain number are preceded 
by definite sensations and warnings. The term aura is applied to a 
singular phenomenon preceding the attack and indicating its approach. 
Ko longer used, in accordance with its original signification, as a breath, 
this term expresses any manifestation, sensory, motor, or psychical, 
which gives warning of a paroxysm : it may be the sensation of a 
breath, the flowing of a hot or cold liquid, numbness, tingling, even a 
severe pain passing with great rapidity from the periphery to the 
brain. Again, the aura may consist of an impression on an organ of 
sense, as a flash of light, a strange odor, or a rumbling noise in the 
ear ; or in some local muscular spasm or cramp ; or some specter or 
other hallucination rising up in the mind. Warnings may be more 
remote, occurring some days before the seizure, when they take the 
shape of mental or moral perturbation ; sadness and despondency of 
mind, a gloomy reticence and suspicion are experienced, or an excited, 
irritable, quarrelsome, even dangerous and malignant state of mind 
comes on. More frequently than these symptoms occur merely head- 
ache, dizziness, and some confusion of mind, for a few hours or a day 
or two before the seizure. In a large proportion of cases seen by the 
author, the prodromal symptoms consisted in a sense of praecordial 
oppression, epigastric uneasiness, and nausea, the attack following 
immediately on the rise of a peculiar sensation from the epigastrium 
to the brain.* With or without an aura, the epileptic paroxysm when 
it occurs is sudden. It consists of four distinct acts : a sudden fall ; 
loss of consciousness, with pallor of the face ; a peculiar cry ; general 
convulsions. In any situation or place the individual attacked hap- 
pens to be, he falls — down the stairway, into the fire, against an article 
of furniture ; or if, mercifully warned by some sensation, he has the 
opportunity, he places himself in a position of safety. The fall may 
be to one particular side, on which scars will be found to indicate the 
direction taken in falling. The fall occurs because loss of conscious- 
ness supervenes, and the control is at once withdrawn from the volun- 
tary muscular system. Sensibility, motility, perceptions, the special 
senses, the reflex func*oions even, are at once and entirely abolished. 
The face grows deadly pale, and this is due to a sudden spasm of the 

* Gowers (" Gulstonian Lectures," " Lancet," March 20, 1880) says this sensation 
occurred in one half of bis cases. 



694 



DISEASES OF TEE NERVOUS SYSTEM. 



arterioles of the head, whence the amount of blood passing to the 
brain is greatly reduced. At the moment that unconsciousness takes 
place, a peculiar cry is uttered, " shrill and terrifying to man and 
beasts," is the description of Romberg.* It may be a mere groan, and 
there may be an entire absence of all sound. Immediately on the 
occurrence of pallor of the face, the muscles of the body generally 
assume a position of tetanic rigidity ; the head is drawn back or to 
one side, where it is firmly held ; the jaws are tightly closed, the 
lips retracted into the sardonic grin, the eye fixed in a stern expres- 
sion, the brow corrugated ; the fingers and toes are extended, widely 
separated ; the respiratory muscles similarly tetanized, respiration is 
suspended ; the pulse is small, firm, and variable in frequency ; a 
rapid venous stasis, cyanosis of the face, and blueness of the lips suc- 
ceed to the momentary deathly pallor, because of the arrest of respira- 
tion and compression of the great venous trunks by the rigid cervical 
muscles. Just as the tetanic stage begins, a loud, strong, and pro- 
tracted whistling inspiration is made, and then ensues the rigidity of 
the respiratory muscles. The tetanic condition may not be universal, 
may be limited to a few muscles, as those of the head and eyes, the 
spasms being clonic at the outset ; or there may be no rigidity, the 
muscular twitching beginning at once, or, on the other hand, there may 
be nothing more than transient rigidity of the voluntary muscles. 
This rigid stage lasts from a minute to a minute and a half, and is 
succeeded by the stage of clonic convulsions. At first the muscles of 
the face, lips, tongue, pharynx, and larynx begin to twitch, the face 
to make horrible grimaces, the eyes to roll in their sockets. The face 
is still blue, the lips blue, but, as respiration goes on, the blueness is 
mixed with red, the superficial veins are swollen, the lips are extruded 
with each expiratioQ and are covered with froth, often with bloody 
froth, the breath issues with a whistling, stridulous noise, the inspira- 
tion being labored, loud, sonorous, the teeth grind together, and often 
the cheek or tongue is caught and chewed, thus furnishing the blood 
which is mixed with the froth. The muscles of the extremities are 
violently agitated, thrown about, and with such violence that severe 
injuries are sustained, even fractures of the long bones or dislocations. 
Vessels give way and ecchymoses of greater or less extent are formed 
about the eyelids, and in the mucous membrane of the tongue and lips. 
By these marks may be ascertained the existence of nocturnal epilepsy, 
which otherwise remains undiscovered. The clonic stage lasts one, 
two, or three minutes, and its close is announced by the subsidence of 
the convulsions ; they occur less and less, and at length there is only 
an occasional twitch of the muscles about the mouth, and presently all 
is still, the individual passing into deep sleep, in which the iris, before 



" On Nervous Diseases," " Sydenham Society's translation," by Sieveking. 



EPILEPSY. 



695 



dilated, contracts, the respirations become regular, deep, and full, the 
muscular system relaxed, and the skin warm and perspiring. There 
may be, indeed, a conditien of coma lasting several hours after the 
convulsive stage, and fecal and seminal discharges may occur involun- 
tarily. The duration of the comatose stage varies from a few minutes 
to several hours, and the patient rouses with a rather surprised, or 
dazed, or sheepish expression, and is entirely ignorant of the affair 
through which he has just passed, unless the bitten tongue or cheek 
reminds him of former experiences. Usually the effect on the mental 
and moral state is that of improvement, and the patient feels better 
than before. Attacks may succeed to attacks. Without coming out of 
the condition of coma, another convulsion succeeds to the previous one. 
In other cases the recovery from each paroxysm is complete, and the 
convulsions occur with a distinct interval of an entirely normal state. 
The number of paroxysms during a period of twenty-four hours may 
be from one to fifty — even more. Immediately succeeding the con- 
vulsions in some epileptics, there occur attacks of delirium or hallu- 
cinations, or they pass into an excitable, quarrelsome state, and are 
prone to commit homicidal acts. Physicians have frequently to testify 
as to the mental condition of epileptics, on trial for acts committed in 
the mania which succeeds to convulsions. 

The apoplectic form of Jaccoud differs from the ordinary form 
just described, by the depth and duration of the succeeding stage of 
coma, by the evidences of cerebral congestion present, and by the 
paralysis — temporary or more permanent — usually in the form of 
hemiplegia, succeeding to the clonic convulsions. The second form — 
epilepsia mitior, milder epilepsy, or petit mal — exhibits iself in the 
two forms of vertigo^ or vertiginous sensations, and absence or in- 
stantaneous unconsciousness in the sphere of ideation. In the former, 
the patient is seized with a severe vertigo, in which all surround- 
ing objects are in motion, and he is unable to maintain the upright 
position, and would fall if not supported. With the vertigo there 
is loss of consciousness lasting for a second, when the normal state 
is restored. Usually, the vertiginous sensations and the loss of con- 
sciousness are accompanied by some partial convulsive phenomena ; 
as grimaces, twitching of the muscles of the face, grinding of the 
teeth, movements of rotation of a member — of the arm, for example 
— or of the whole body, running forward suddenly. On an instant 
consciousness returns, the patient looks around with a foolish expres- 
sion, it may be, and the attack is over. By absence is meant ab- 
sence of mind, but not in the popular sense — in the technical sense, 
in this connection, of total abolition of ideation, for an instant of 
time. The attack may occur at any time, and consists in the most 
transient suspension of consciousness — in the midst of a sentence, sew- 
ing, walking, or writing : for the instant all thought is suspended ; 



696 



DISEASES OF THE NERVOUS SYSTEM. 



the sentence being uttered, the sewing, the walking, or the writing is 
stopped, and then immediately resumed, so that the brief gap may- 
attract no attention. Observing the appearance of the individual thus 
attacked, there will be seen a sudden pallor of the face and dilatation 
of the pupil, but no other objective phenomena. These forms of epilep- 
sia mitior may precede, for a long time, the fully developed attacks, 
or may occur with them. The popular notion of the little importance 
of these seizures is not justified by the results, for absence is particu- 
larly injurious to the mental faculties. In all of these forms of epilepsy 
the loss of consciousness is the central fact, and without it, according 
to many, there can be no epilepsy. There are, however, numerous ex- 
amples of convulsions, partial and general, without loss of conscious- 
ness. Dr. Hughlings Jackson * defines epilepsy as " a sudden^ exces- 
sive, and rapid discharge of gray matter of some part of the brain on 
the muscles." It does not necessarily involve the loss of consciousness. 
His notion is that any mass of gray matter may get into a highly ex- 
cited state by some kinds of irritation — " reaches very high tension 
and very unstable equilibrium, and therefore occasionally 'explodes.'" 
Irritation of a part, the destruction of which causes hemiplegia, will 
induce unilateral convulsions of the same region. Local convulsions, 
as in an arm, for example, may therefore be a " discharging lesion of 
a small extent of irritated gray matter." There are masked or con- 
cealed epilepsies, taking the form of tic-douloureux, or neuralgia of 
the fifth nerve, convulsive tic, or histrionic spasm, and angina pectoris. 
After a time the paroxysms assuming these forms take on the proper 
epileptic character, or the epileptic seizure alternates with its counter- 
feit. Again, epilepsy may take the form of an acute delirium (Fal- 
ret's delirium epilepticum) . The peculiarity of this affection is its 
sudden and unaccountable appearance, and its equally prompt and un- 
expected disappearance. Often the delirium takes the form of an 
" insane impulse," in which acts of violence are committed, or of ob- 
scene and violent language, or of some senseless conduct. It may be- 
come excessively violent and destructive, leading to the performance 
of atrocious murders. This condition of mind is transient and disap- 
pears in a few hours or in a day or two, and the patient is either to- 
taUy unconscious or has the remembrance as of a vague dream. 

Course, Duration, and Termination. — Epilepsy is one of the most 
chronic of diseases, and its duration numbers many years. At the out- 
set there may be many months' interval between the attacks, but, as 
the case progresses, the attacks increase, and the intervals between 
them become shorter. The periods of return are very irregular. Kow 
and then attacks strictly antiperiodic are encountered, and others are 
connected with the menstrual functions. As attacks are often deter- 
mined by preventable causes, the number may be much increased by 

* " A Study of Convulsions," and " On the Investigation of the Epilepsies," and vari- 
ous papers. 



EPILEPSY. 



697 



indiscretions. Among these are indulgence in alcoholic fluids, sexual 
excesses, and errors in diet. Probably the last named is the most 
important of these noxious influences. Nocturnal attacks may escape 
recognition for a long time, and the origin of the disease dates from 
some diurnal attack, or from a seizure in which the bitten tongue, 
ecchymoses, and general muscular soreness served to indicate the 
nature of the disturbance. An unexpected decline in mental power, 
changes in the disposition, and impaired health in certain directions 
without any apparent reason, may be explained by nocturnal epileptic 
attacks. The existence of epilepsy is not incompatible with a condition 
of perfect health. In the interval between the attacks, still more in 
the future progress of the cases, various alterations in the motor, sen- 
sory, and intellectual sphere are produced. In the motor group may 
be mentioned clonic convulsions or clonic or tonic spasms in a single 
extremity, or group of muscles ; in the sensory, numbness of certain 
areas in the extremities, headache, neuralgia, etc. The most important 
results of epileptic seizures are changes in the intellect, weakness of 
memory, impaired judgment, etc., gradually increasing until ultimately 
these unfortunates pass into the condition of dementia. Occasional 
epileptic attacks do not seem to have much influence on the condition 
of the mind, and in confirmation of this opinion are always quoted the 
cases of Csesar, Napoleon, and Petrarch. The statistics of Reynolds 
prove that the number of attacks alone is not responsible for the effect 
on the intellect, but the mind suffers more when the attacks follow in 
quick succession. Epileptics early suffer changes in the moral sphere, 
in the affections, the disposition, and the emotions, before any intel- 
lectual decadence is observed. Although the prognosis is unfavorable 
as respects cure, decided amelioration can be effected in a large pro- 
portion. A few cases are cured, and the number of cures increases 
with the improvements in therapeutics. The earlier the treatment is 
undertaken the more favorable the termination. The less the number of 
attacks within a given period and in the aggregate, the more favor- 
able. If there be a distinct peripheral cause, as injury to a nerve, a 
tape- worm, etc., the prognosis is more favorable ; but, when the status 
epilepticus is established, it does not suffice merely to remove the cause. 
If central lesions exist, the termination by recovery seems quite im- 
possible. Heredity apparently increases the intractability of the dis- 
ease, but some notable exceptions have been published. JSTocturnal 
attacks are less amenable to treatment than diurnal. The forms of 
epilepsia mitior are, as a rule, more difficult to manage than epilepsia 
gravior. Absence especially has disastrous effects on the mind. Fi- 
nally, treatment has an important influence for good or evil over the 
course, duration, and termination of epilepsy in all its forms. 

Treatment. — The success of the management of epilepsy depends 
largely on the skill with which various sources of peripheral irrita- 
tion are investigated and removed. Every case, therefore, requires 



698 



DISEASES OF THE NERVOUS SYSTEM. 



the most deliberate and searching investigation. Has there been an 
injury ? Is it of the cranium or of a peripheral nerve ? Many cases 
have been cured by the application of the trephine, and the number is 
increasing. So favorable have been the results of this practice that, 
if a severe blow on the cranium has been followed by epilepsy, and 
any injury of the bone can be detected, the trephine should be used. 
Cicatrices so situated as to exercise pressure on a nerve should be dis- 
sected out — a practice of special necessity when an aura or any uneasy 
sensation starts from the affected part. If there be a defined aura so 
situated as to be intercepted in its passage to the brain, various expe- 
dients have been resorted to for this purpose, as a ligature about the 
thigh, leg, or arm, the application of a blister to surround the limb, or 
the cauterization, by nitrate of silver, of a band around the extremity. 
Permanent relief has been obtained by cutting down on the point 
whence an aura proceeds, and not only removing a source of irrita- 
tion, but dividing or stretching a nerve-trunk. When the impression 
arises at the epigastrium and passes thence to the brain — probably 
the most frequent of all prodromic symptoms or warnings — most care- 
ful attention must be given to the diet. The author has witnessed 
more good from regulation of the diet than from any mode of medica- 
tion. Epileptics eat largely and bolt their food. When stomachal 
symptoms exist, an epileptic should be restricted to the milk-diet for 
several weeks, and should then gradually have additions made to it ; 
but the permanent diet should not exceed milk, eggs, a little meat once 
a day, a single vegetable, a very little bread and butter, and one fruit. 
Restriction to this plan of diet will often effect remarkable improve- 
ment. If there be worms present in the canal, they should of course 
be expelled. If stomach syrajDtoms are present, good results are ob- 
tained from drop-doses of Fowler's solution three times a day, from 
half -grain doses of the oxide or nitrate of silver, or a suitable quantity 
of oxide of zinc. These remedies are beneficial only in cases of epi- 
lepsy dependent on stomachal derangements. The danger of staining 
by the use of silver remedies should not be overlooked. From the nega- 
tive point of view there are several important questions connected with 
the stomach and alimentation. Coffee, tea, tobacco in any form, and 
all kinds of alcoholic drinks, must be forbidden to all classes of epilep- 
tics. It is important to prevent paroxysms, since habit enters largely 
into the mechanism of epileptic seizures. The means of intercepting 
an aura have been referred to. Brown-Sequard suggests various pe- 
ripheric irritations — pulling on the great-toe, inhaling a little carbonic- 
acid gas, etc. The inhalation of ether and chloroform may render the 
attacks less severe, but the practice is questionable. When the attacks 
are nocturnal, a sufficient dose of chloral, or better, the hypodermatic 
injection of morphine at bed-hour, will act most efficiently to prevent 
them, but as the morphine habit will be quickly formed, other reme- 
dies should be preferred. The nitrite of amyl by inhalation will 



HYSTERIA. 



699 



often avert an impending attack. The advantage of this remedy con- 
sists in the facility with which it is employed. A perl containing 
three to five minims can be broken up in a handkerchief and inhaled 
without delay. Nothing should be done during the paroxysm but re- 
lieve the body of all constricting bands, and put the epileptic in a 
position where he will not injure himself. The question of a suitable 
remedy for the disease is by no means a complicated one. There can 
be no question of the superiority of the bromides, and notably the 
bromide of potassium, over all other remedies. Their long-continued 
use is attended with few disadvantages, and the mental condition 
improves rather than declines under their employment. The bro- 
mides of sodium and potassium are chiefly administered, but while 
the potassium bromide is rather more effective as a remedy, the so- 
dium bromide is far less hurtful, and should be preferred in cases re- 
quiring the protracted administration of such remedies. The point to 
arrive at in the course of the use of the bromides is an ansesthetic 
state of the fauces — an important fact which we owe to Yoisin. The 
fauces must have their reflex sensibility so far reduced that no move- 
ments are excited by touching the palate, base of the tongue, or any 
part of the throat. The amount required to produce this result will 
vary, according to the individual susceptibility, from one half to two 
drachms per day, but it should be borne in mind that it is not the 
quantity of the medicine required, but the effect produced, which 
should guide the administration. Bromism may be prevented by the 
occasional use of a purgative, by maintaining free action of the kid- 
neys, and by combination with Fowler's solution, two or three drops 
morning and evening. Next to the bromides, probably, are strych- 
nine and picrotoxin in utility. The author has given strychnine with 
the bromides in cases of epilepsy occurring in weak and anaemic sub- 
jects. It is adapted to those cases in which there is mere instability 
of nervous matter, due largely to ansemia, and is contra-indicated in 
those cases characterized by exalted reflex excitability, with peripheral 
irritation. In the treatment of epilepsy by bromides, the mistake is 
made of giving it irregularly, or of suspending it capriciously. It should 
not be suspended, even if bromism occur ; it should be diminished in 
amount and active elimination set up, and then resumed in the dose 
necessary to maintain anaesthesia of the fauces. It should be continued 
for a long period after the convulsions have ceased, probably not less 
than two years. 

Cases of nocturnal epilepsy are not so much benefited by the bro- 
mides as the diurnal. In the former the author has seen better results 
from picrotoxin, and from curara, especially. In nocturnal cases char- 
acterized by depression, phosphorus and phosphide of zinc have 
seemed to do much good. In the state entitled " absence," 77ial, 
and in epileptic vertigo, nitro-glycerine has acted favorably. 



700 



DISEASES OF THE NERVOUS SYSTEM. 



HYSTERIA. 

Definition. — Hysteria is a functional nervous trouble, characterized 
by various motor, sensory, and intellectual disturbances, and by ex- 
cessive variability in their seat and manifestation. 

Causes. — Hysteria is almost exclusively confined to women, and 
only occasionally witnessed in men. The sexual condition, the social 
habits, the repression which a very limited sphere of activity enjoins, 
and a much greater mobility of the nervous system, are supposed to 
be the chief reasons for the relatively greater prevalence of hysteria in 
females. The age at which hysterical manifestations appear is not a 
fixed one, and, although most frequent from puberty on for ten or 
more years, attacks occur from childhood. In Briquet's collection of 
four hundred and twenty-six cases, two hundred and twenty-one ap- 
peared between the twelfth and twentieth years of life. Undoubtedly, 
that mobility of the nervous system, and instability, on which the 
manifestations of hysteria depend in the mother, are transmitted to the 
daughter. If the so-called neurotic type of constitution is inherited, 
in one generation it may assume the shape of hysteria ; in the next, epi- 
lepsy ; and in the third, insanity. But the hysterical type, as such, is 
more directly inheritable. That derangement of the female sexual 
organs — especially of the uterus and ovaries — is the essential cause of 
hysteria, is an opinion no longer entertained in any quarter. It can 
not be too strongly insisted on that there is a peculiar morbid state of 
the nervous system — a neurosis — either inherited or acquired, and that 
various kinds of disturbances may excite the morbid manifestations. 
These disturbances may be in the sexual system, in the digestive, in 
the circulatory, or in the nervous. This peculiar state of the nervous 
system may be acquired by faults of early training, by a lack of per- 
sonal discipline, by frequent alternations of feeling, by mortification, 
chagrin, and other moral and emotional excitements. That hysteria 
may exist independently of sexual causes is quite proved by the fact 
that violent hysterical paroxysms occur in women congenitally defi- 
cient, and wanting in uterus, and ovaries, and all sexual characteristics. 
The instability of the nervous system belonging to hysteria is much 
increased by certain physical causes — notably by anaemia. When the 
blood is impoverished, the nervous tissue becomes excessively irritable, 
and the discharges of nervous force are frequent and irregular, while 
deficient in sustained force. 

Pathogeny and Symptoms. — No structural alterations have been 
detected in the centers where the disturbances of function exist. Hence 
hysteria is properly a neurosis — a functional disorder. The old notion, 
that uterine disease is a necessary element in hysteria, as the word 
indicates, has long been abandoned. The first manifestations of hys- 
teria are usually trivial — mere irritability or mobility of disposition ; 
rapid changes of feeling without apparent motive ; noisy and tempes- 



HYSTERIA. 



YOl 



tuous transitions of sadness and joy, tears and laughter. In the course 
of development, physical are added to these merely psychical changes ; 
quick and unaccountable alternations of cold and heat, that are purely 
subjective, and felt usually in the extremities ; numbness, tingling, 
and other altered sensations, which are extremely irregular, now severe, 
awakening fears of paralysis, now forgotten in the presence of some- 
thing interesting to occupy the attention, access of suffocative feel- 
ings, " pain around the heart," palpitations, quick breathing, a sense 
of fullness of the stomach, eructations of gas, and the rising of a globe 
to the larynx (globus hystericus), producing a sensation of choking ; 
alternate flushing and pallor of the face ; restlessness ; the whole end- 
ing, it may be, in prolonged laughter, but more usually in crying, and 
in a profuse urinary discharge, the urine being pale and watery. Such 
an attack may occur, with more or less frequency, in a young woman 
of good health otherwise, and may never advance beyond this. In 
addition to the symptoms just described, there may be spasmodic phe- 
nomena, tonic and clonic. When the more severe attacks approach, 
they exhibit alternations of chilliness and heat, they yawn and gape a 
great deal, the limbs are in a condition of unrest, of "fidgets," they 
laugh and cry, and equally without reason, they urinate frequently, 
the heart palpitates, they choke with a ball rising up into the throat 
and gasp for breath, sobbing, and coughing with a loud, metallic clang, 
the jaws are fixed, the face retracted, the teeth grinding together, the 
hands clinched, the limbs drawn up and rigid. Such are the phe- 
nomena of the tonic convulsion. In a few minutes, usually, or in an 
hour or two, the attack subsides, the patient sheds a flood of tears, 
passes a large quantity of limpid urine, and goes to sleep exhausted. 
In other cases, a brief stage of tonic rigidity is succeeded by irregular 
clonic convulsions, the patient throws her limbs about, screams, tears 
at her throat to remove the choking sensation, sobs, gives forth re- 
peated, loud hiccough, the abdomen is full of gas, and there are loud 
borborygmi ; sometimes the pelvis is moved in a rhythmical manner, 
and the limbs are fixed. There is no loss of consciousness, the reflex 
movements of the iris and eyelids are preserved, and, although the 
jaws are rigid, if fluid reach the fauces it is soon swallowed, and the 
realization of surrounding events is preserved. As a result of the vio- 
lent muscular efforts, the skin, which was at first cool, becomes warm 
and perspiring. These convulsions last for several minutes, or as 
many hours. They subside in a flood of tears, the body is completely 
exhausted, and the patient sinks into a deep sleep. During these 
attacks, usually, the reflexes are increased, and pressure on certain 
regions of the face, head, or spine, or on the ovaries, will increase the 
convulsive movements. According to Charcot, pressure on an ovary 
will excite attacks, and firm pressure may arrest hystero-epilej^sy. In 
some cases there are no convulsions, but the patient passes into ecstasy, 
a, condition of fixed immobility and death-like pallor of the face, half- 



702 



DISEASES OF THE NERVOUS SYSTEM. 



closed eyes, almost suspended respiration, extremely feeble, hardly 
distinguishable pulse — an appearance of death. In other cases, the 
condition of ecstasy is associated with catalepsy — in which the limbs 
retain the position in which they are placed. The duration of the 
cases varies. Instead of terminating, in a certain proportion there are 
remissions merely, and hence the attacks may persist for several days. 
The critical evacuations which announce the end of the seizure do not 
occur in the remissions. There are no regular periods of return, except 
that they are more apt to be present during the menstrual periods, and 
do not occur at night. If the moral or mental state and the bodily 
conditions which favor the attacks continue in operation, a succession 
of seizures may be expected. 

Hysteria is associated with widespread disorders in the sensory, 
motor, psychical, and vaso-motor systems, which appear at the onset 
of the disease or during the intervals between the attacks. The retina 
may be so sensitive to luminous impressions that the least light be- 
comes intolerable ; hence it is that so often the hysterical are found in 
dark apartments. Flashes of light and floating objects appear before 
the eyes ; more complex impressions of scenes and persons are repro- 
duced, and hallucinations are perceived. In the same degree hyper- 
sesthesia of the auditory is present, and even a whisper causes pain, 
while various loud, roaring, subjective noises are heard. Sometimes a 
remarkable acuteness of hearing is developed, and out of this may 
grow conscious deceptions. The hysterical, like the insane, may hear 
voices, but the results differ in the important respect that the former 
realize their origin. The sense of smell in the hysterical is much per- 
verted, and they are acutely sensitive to odors. Remarkable perver- 
sions of taste are also manifest. The hysterical have a propensity for 
eating ch.alk, slate-pencils, sealing-wax, etc. As regards general sen- 
sibility, there may be more or less hypersesthesia and hyperalgesia, 
in particular spots or areas, and between these areas of anaesthesia. 
Pain is one of the most usual and widely distributed of the sensory 
disturbances in hysteria, and headache is the most common form. 
There may be general headache, with such a degree of hypersesthesia 
of the scalp that combing the hair is painful. The headache may be 
localized to a particular point at the top of the head, or to one temple, 
or to the supra-orbital ridge, may be exceedingly violent, and accom- 
panied by chilliness and feverishness, nausea, vomiting, and constipa- 
tion. This form of headache has been called clavus hystericus. It is 
very apt to come on at or about the menstrual epoch. Neuralgic pains 
occur in the mammre, which become irritable and tender, or in the 
praecordial region, which are always referred to the heart, and in the 
left side, about the sixth or seventh intercostal space. The last-men- 
tioned pain is more frequently referred to than even the headache. 
Hysterical women suffer greatly from the evolution of gas in the in- 
testine, and hence colics are frequent. Hyperaesthesia of the abdomi- 



HYSTERIA. 



Y03 



nal wall may also be present, and simulate peritonitis ; but exquisite 
pain is complained of before the skin is touched, and, when the atten- 
tion is withdrawn, the abdomen can be pressed upon without any flinch- 
ing. Gastralgia is a very usual symptom ; emptiness, abnormal full- 
ness, boulimia, and an utter disinclination for food, are among the very 
contradictory sensations. The presence of a parasite and its move- 
ments are often insisted on. An irritable bladder is a common 
symptom. Pain in the extremity of the coccyx, or coccydinia, is com- 
plained of, usually after the first confinement, or from the results of a 
blow, and is a peculiarly unmanageable symptom. The much-debated 
spinal irritation is also an extremely frequent symptom in cases of 
hysteria. It consists in tenderness and pain on pressure of the spinous 
processes of a few vertebrae, or of the parts immediately adjacent. 
Spinal irritation has no more importance than any of the pains which 
occur in the course of hysteria. The joints are similarly affected, es- 
pecially the knee, which becomes painful and swollen the more the 
attention is fixed on it. This affection, first described by Sir Benja- 
min Brodie, is known as the hysterical joint. The peculiarity of it is 
the occurrence of pain and swelling rather around than in the joint, 
but often the joint is simply rigid in a position of flexion. Extensive 
spots, entirely anaesthetic, occur in hysterical subjects. Analgesia 
may be present to such a degree that extensive injuries can be in- 
flicted without consciousness of pain. The anaesthesia may be limited 
to one side — ^hemianaesthesia. The muscular sense and the apprecia- 
tion of weight may be lost, and the senses of touch and temperature 
retained. Amblyopia may be the result of anaesthesia of the retina. 
Paralyses in the course of hysteria are numerous and perplexing. 
Dysphagia may exist from paralysis of the pharynx, aphonia from 
paralysis of the vocal cords, and both may occur on the instant, and 
disappear as suddenly. Paralysis of the bladder and retention of urine, 
requiring the catheter, is a common symptom of hysteria. Paralysis 
of a member, of several, or of muscular groups, known as hysterical 
paralysis, assumes various characters : one extremity may be affected, 
or one upper and one lower extremity on opposite sides ; it may take 
the form of hemiplegia, of paraplegia, or all four extremities may be 
affected simultaneously. It may be partial or complete ; it may come 
on gradually, or appear suddenly after a fit, or without any reason. 
The electric reaction is normal, unless the limbs are wasted from long 
disuse. There may be anaesthesia with the paralysis, but not neces- 
sarily, and, when that is the case, the electro-sensibility is wanting. 
On this Dachenne founded a distinction between hysterical and other 
forms of paralysis, but incorrectly so, since in some the sensibility is 
normal or even increased. The duration of hysterical paralysis is 
very variable ; it may continue for a few hours, a few days, many 
months, or several years, and it may unexpectedly disappear from one 
part to attack another. With or without palsy there may be contrac- 



Y04 



DISEASES OF THE NERVOUS SYSTEM. 



tion, or after the paralysis has existed for some time the contraction 
may come on. In the upper extremity, a spasmodic flexion of the fin- 
gers, hand, or forearm may occur ; in the lower, spasmodic extension 
of the hip, knee, and ankle-joints. The behavior of the contractions is 
the same as the paralysis — they continue a variable period, to be sud- 
denly terminated by some moral influence. Yarious disturbances en- 
sue in the realm of the vaso-motor nervous system — irregularity and 
weakness in the heart's action ; amenorrhoea and dysmenorrhoea ; epis- 
taxis, haemoptysis, and hasmatemesis ; stigmatizations. As extraor- 
dinary ingenuity and perseverance and self-denial are employed to 
execute the deceptions by which they produce the appearance of these 
maladies, to excite sympathy and attention, the physician must be on 
his guard lest he be led into error. Remarkable mutilations and per- 
sonal injuries are effected, to excite sympathy or wonder in those about 
them. Influenced by a morbid craving for strange excitements, an 
hysterical girl will injure an infant, burn a house, stick things under 
the skin, drink her urine to make believe that none has passed, produce 
pins as having come from the bladder, or draw a dead animal from the 
vagina, etc. Indeed, there is scarcely a limit to the extraordinary fan- 
cies or to the eccentric acts of the hysterical. Besides these perverse 
and singular acts, growing out of moral perversion, the hysterical may 
undergo forms of mental derangement, the most persistent ending their 
days in asylums. In some, the mental disorder takes the place of melan- 
cholia, and they tend to injure others or to the commission of suicide, 
to give vent to their notions of misery. In others, the disorder is in 
the direction of moral mania : they steal, injure articles of clothing, or 
set fire to the house ; they are given to sexual vices, to strong drink, 
and are utterly without a moral sense. In others there will be devel- 
oped mania with delusions, often of a religious kind. 

Course, Duration, and Termination. — Beginning often at a com- 
paratively early period, hysteria reaches its highest development from 
puberty to thirty-five, afterward decreasing, to disappear in old age. 
Those developing slowly under hereditary influence and by example 
are the most difficult to cure. In that admirable little book, " Fat and 
Blood," Mitchell describes with a master hand the course of many 
cases : " But no matter how it comes about, the woman grows pale 
and thin, eats little, or if she eats does not profit by it. Everything 
wearies her — to sew, to write, to read, to walk — and by and by the 
sofa or the b^d is her only comfort. Every effort is paid for dearly, 
and she describes herself as aching and sore, as sleeping ill, and as 
needing constant stimulus and endless tonics. Then comes the mis- 
chievous role of bromides, opium, chloral, and brandy. If the case did 
not begin with uterine troubles, they soon appear, and are usually 
treated in vain if the general means employed to build up the bodily 
health fail, as in many of these cases they do fail. The same remark 
applies to the dyspepsia and constipation which further annoy the 



HYSTERIA. 



705 



patient and embarrass the treatment. If such a person is emotional, 
she does not fail to become more so, and even the firmest women lose 
self-control at last under incessant feebleness. If no rescue comes, the 
fate of the woman thus disordered is at last the bed. They acquire 
tender spines and furnish the most lamentable examples of all the 
strange phenomena of hysteria." Under the influence of marriage 
and child-bearing, the hysterical troubles may disappear entirely or 
for a long period, returning from time to time, but much less severely. 
In most cases there are remissions and exacerbations, and those cases 
characterized by the most severe symptom may have the shortest 
duration. The danger to life is inconsiderable. The probability of 
mental disorder arising is slight, but the prospect of cure is, in the 
cases of long duration, very remote and uncertain. 

Diagnosis. — The diagnosis of hysteria rests on the age, sex, the 
variability and diffusion of the symptoms. There is no possibility of 
mistaking an attack of vapors. Epilepsy is distinguished from the 
convulsions of hysteria in the order with which the several stages occur, 
in the loss of consciousness and the abolition of reflex movements, biting 
the tongue or cheek, the after-coma, and in the absence of hysterica 
phenomena in the interval. In those cases of epilepsy occurring in 
hysterical women, there may be no points of difference, when it may 
be assumed that the two maladies occur together. Hystero-epilepsy 
presents some remarkable features, especially as regards the condition 
of tonic rigidity, so that it must always be readily recognized. The 
influence of pressure on the ovaries and the singular history in these 
cases will contribute to the facility of diagnosis. Hysterical palsies 
of every kind are distinguished by the preservation of the electro-con- 
tractility, and the occasional absence of electro-sensibility, by the ab- 
sence of all trophic disturbances, and by the history of hysterical trou- 
bles of various kinds. In hysterical hemiplegia there is no facial 
paralysis, and no apoplectic seizures precede the hemiplegia. 

Treatment. — In this malady, above all others, are moral and hy- 
gienic measures of most importance. When the hysterical constitution 
is inherited, prophylactic methods should be pursued from an early 
period. SeK-control should be instilled into the mind from the first 
dawn of intelligence, and the muscular and digestive systems should 
be cultivated, while the nervous is trained to subordination. Early 
hours, substantial food, plain clothing adapted to the needs of the 
body, should be insisted on, while society, the follies of dress and 
fashion, and dainties, should be prohibited. The utmost care is neces- 
sary in the selection of books for young ladies. The modern novel 
has done much mischief by cultivating morbid fancies and false notions 
of the relation of the sexes, etc. Sexual abuses, although less influ- 
ential than usually supposed to be, do have an injurious effect on the 
nervous system. If the hysterical condition develops in spite of the 
precautions advised, remedial measures become necessary. The con- 
47 



706 



DISEASES OF THE NERVOUS SYSTEM. 



dition of angemia must be removed by chalybeates, a generous diet, 
and suitable exercise. Those tonics are most suitable which have a 
special direction to the nervous system, as arseniate of iron, strychnine, 
and the phosphates. As the opposite condition or plethora may exist, 
although less common than anaemia, iron, arsenic, and strychnine should 
be avoided, and such remedies as the bromides, gelsemium, and cimi- 
cifuga prescribed. For simple hysterical seizures without convulsions, 
the elixir of valerianate of ammonia, a camphor julep, a little fluid ex- 
tract of valerian, or a few drops of Hoffman's anodyne, repeated every 
few minutes, will terminate the seizure. In the convulsive form, as the 
trismus is difficult to overcome, inhalations of amyl nitrite or of ethyl 
bromide may be practiced, rectal injections of turpentine, ammoni- 
ated valerian, tincture of assafoetida, or, in violent cases, a minute 
quantity (y^g- gr.) of morphine, hypodermatically, may be adminis- 
tered. For the various complications of hysteria the resources of the 
therapeutist are severely tried. Migraine or clavus may be cured by 
attention to the general health, and by such remedies as guarana, coca, 
nux vomica, arsenic, aconitine, galvanism, etc. Hysterical aphonia and 
dysphagia may sometimes be cured instantly by faradic applications. 
Anaesthesia is most successfully treated by the electric brush, a strong 
current being applied after drying the part well. The various forms 
of hysterical paralysis require faradic applications. A single appli- 
cation may overcome paralysis of long standing, especially if the im- 
pression made by the electricity is seconded by tact and moral force 
on the part of the physician. Mitchell has devised a plan of treatment 
for bed-fast hysterical subjects which seems very successful. It consists 
in the combined use of massage, faradizations, and forced feeding. 
Massage consists in friction, kneading and tapping of all the muscles 
except those of the face, in passive motions of all the joints, and in 
muscular motions produced by faradic applications. The frictions are 
made with lard or cacao-butter. The diet consists at first of milk only, 
but additions are made to it from time to time, until ultimately the 
feeding is very liberal. No exercise is allowed, but all movements are 
made for the patient, which is exercise without voluntary effort. Re- 
markable gain in weight takes place, and when the improvement 
reaches a certain point systemic voluntary exercise is begun. An im- 
portant point in Mitchell's treatment is the separation of the patient 
from all her former associations and the superabundant sympathy of 
home. She is placed in charge of a nurse, on a diet of milk ; hunger 
takes the place of her indifference to food. She is placed in bed, and 
not permitted to move ; the desire for action grows out of the utterly 
monotonous idleness. She is acted on by the electrical force, and by 
the moral force of her new environments, and stimulated to wise think- 
ing by the ingenious suggestions of an acute-minded physician. The 
result is she is cured. 



NEURASTHENIA. 



707 



NEURASTHENIA— SPINAL IRRITATION. 

Definition. — The term neurasthenia was originally applied by 
Bouchut * to signify the nervous state. This application of the term 
was revived by Dr. George M. Beard, who also extended its mean- 
ing.f It is now employed to designate an exhaustion of the nervous 
system, occurring in a peculiar type of constitution — the neurotic 
temperament. 

Pathogeny. — The most important pathogenetic factor is a peculiar 
type of nervous system, usually inherited, or constructed by the union 
of parents having a predominating nervous system. This type is char- 
acterized by precocity in the development of the mind ; by a nervous 
system of exceeding susceptibility to impressions of all kinds ; by 
feebleness of the function of digestion ; by an imperfect secondary 
assimilation ; and by an inefficient action of the excretory organs. 
The kind of moral and intellectual training to which such subjects 
may be submitted — the cultivation of the feelings and emotions, 
rather than the robuster reasoning faculties — increases the suscepti- 
bility and the mobility of the nervous system. These unfortunates 
acquire the habit of frequent interrogation of their organs, and hence 
become keenly cognizant of all bodily sensations. They thus lay the 
groundwork of a selfish valetudinarianism, which needs but little en- 
couragement to expand into any kind of nervous disturbance. These 
subjects revel in the consciousness of possessing a most irritable ner- 
vous system, and dwell in a moral atmosphere of interminable bodily 
sensations, and are beset by fears that some part may become the seat 
of pain or other nervous disturbance. Very often a nervous girl has 
a foolish mother, or some close relative or friend, who is the confidant 
and repository of her fears, her feelings, and her actual pains, and 
sympathy, suggestion, and approval, magnify her nervous troubles in 
every way. The imagination given loose rein, and the attention fixed 
on some one or all of the organs, the way is prepared, and the nervous 
state inaugurated. Such is the usual development of neurasthenia in 
women. 

In men, the neurotic state existing, neurasthenia is caused by the 
various kinds of disturbance to which men are subjected. Self -abuse 
from puberty to twenty-five ; sexual excesses after marriage, or from 
puberty on ; dyspepsia ; excessive attention to study or business — are 
the chief causes of nervous disturbance in men, prepared for it by 
the training above mentioned. Although to excessive mental work or 
attention to business is ascribed the cause of nervous derangement, 
it is probable that the work is only hurtful because carried on under 
improper conditions. 

Various morbid states of the nervous system have been supposed 
* Axenfeld, " Des Nevroses," p. 478. f " On Neurasthenia." 



708 



DISEASES OF THE NERVOUS SYSTEM. 



to exist in these cases. The spinal pain and tenderness were at 
one time considered to indicate congestion, and the back was cupped, 
blistered, cauterized, and otherwise maltreated. Then the theory of 
spinal ansemia was propounded by Hammond, and the opposite plan of 
treatment was carried out. Dr. Jewell, of Chicago, has announced a 
new theory of the pathogeny of this affection, in which he suggests 
that the " sensitive tract " of the spinal cord is impaired, and that a 
" substantial interstitial loss of the ultimate nerve elements " limited 
to certain " horizontal zones " occurs. These alterations of nutrition 
he supposes may be due to " under-action " and " over-excitation." 
As in the present state of knowledge such changes can not be ascer- 
tained, this theory will be regarded as probable or not, according to 
the success with which it reconciles the known facts. As this malady 
does not shorten life, and as the manifold disturbances of function, 
connected with it, are intimately associated with a peculiar mental 
state, we must regard it as a functional disorder, and one chiefly, if 
not wholly, in the psychic sphere. In fact, there is probably no change 
in the nerve centers, as no deviation from the normal has been detected 
on close inspection. Besides the obvious functional derangement of 
the organs of vegetative life, the most important is in the centers of 
conscious impressions — in that part of the brain where peripheric ex- 
citations of all kinds are translated into consciousness. 

Symptoms. — There is no organ or part of the body free from some 
kind of disturbance. The appetite is poor or capricious, and food 
occasions distress ; in extreme cases, the most bland and simple article 
excites pain and nausea. Pain is experienced in the left side, in the 
left hypochondrium, and is often referred to the position of the apex- 
beat of the heart. Gaseous distention of the stomach and gaseous 
eructations, sometimes of enormous volume, and consisting of air and 
carbonic acid, are usual. Torpor of the bowels, the fgeces in globular 
balls, often coated with mucus, sometimes gray and pasty and soft, 
and flatulence with colic-pains, are always present. The nutrition is 
usually poor, the subcutaneous fat scanty, the muscles flabby and de- 
ficient in power. The pulse is quick, the tension of the vessels low, 
the heart irritable, and attacks of palpitation are frequent. The vaso- 
motor system is in a highly mobile state, shown by the chilliness, 
coldness, and paleness of the hands and feet, which are apt to be 
covered with a clammy moisture, alternate flushings and pallor of the 
face, and the sudden and great variations in the tension of the arterial 
system. 

The special senses are variously affected. The ^yes are usually 
very intolerant of light. At first some difficulty in reading is experi- 
enced, the page is blurred, and frontal headache follows the attempt 
to read for even a few minutes. Then the eyes are shaded by turning 
the head from the light, the blinds are drawn, and reading by artificial 



NEURASTHENIA. 



709 



light is given up. Soon all use of the eyes is abandoned, the room is 
kept dark, and the faintest ray of light awakens acute pain and head- 
ache, with vertigo. Hearing is apt to be abnormally acute. Harsh 
sounds occasion distress, and sudden loud noises crash through the 
brain, producing great pain and giddiness, even faintness ; and thus, 
gradually, all light and all sound are excluded from the apartment of 
the most pronounced examples of neurasthenia. Sharp tastes offend 
in food, and disaojreeable odors excite nausea and faintness. 

Probably the earliest manifestation of nervous exhaustion, and 
often the only important one, in men, is an irritability or weakness 
of the mental faculties. After some exhausting effort, literary, scien- 
tific, or in business pursuits, or coming on gradually in the course of 
the daily occupations, it is found that any sustained attention or 
thought excites headache, giddiness, or a strong sense of weariness, 
an obstinate wakefulness that even powerful soporifics only tempora- 
rily relieve, accompanied by a feeling of congestion, of vacuity, of 
coldness, tingling, and creeping sensations in the scalp, sudden con- 
cussions, located apparently in the depth of the brain, and various 
uncomfortable and odd sensations. There is usually a predominant 
idea connected with the mental state ; there is constant dread of apo- 
plexy, epilepsy, or gradual mental failure. These subjects are liable 
to paroxysms of headache, frontal or occipital, accompanied by nausea 
and palpitation of the heart, coldness of the surface, and a tormenting 
dread of immediate dissolution. They become morally cowardly, weep 
on the slightest provocation, and have all of the fancies of the hypo- 
chondriacal and hysterical. 

In the female subjects of this condition, especially, there is much 
spinal tenderness, with the usual phenomena of spinal irritation. 
Males, also, have tender spinal apophyses, but women suffer more 
from this condition. The slightest pressure on one of these spots will 
make them wince, cry out, indeed ; all pressure of stays and of skirts 
is taken of, and the muscles assume odd positions to relieve the parts 
of the weight. Lateral curvature is thus induced ; the muscles on one 
side will be found prominent, rigid, responding with abnormal readi- 
ness to faradic excitation, while the corresponding and symmetrical 
muscles are thin, flattened, and weak. Pains, weakness, and strange 
sensations are referred to the lower limbs. At the outset walking 
soon induces fatigue, and is followed by muscular pains and back-ache. 
Gradually the efforts to take exercise are abandoned, the patient re- 
mains in-doors, then does not leave her room, occupying most of the 
time a rocking-chair and the sofa. The room is jealously closed against 
light and sound, and the patient reclines in the loosest of clothes on 
her sofa or in the bed, every organ in a state of rebellion. Finally, 
all power is lost in the legs ; a strong faradic current causes active 
contractions of the muscles, but there may be complete anaesthesia. 



710 



DISEASES OF THE NERVOUS SYSTEM. 



The sexual functions are always disturbed. In the male there is a 
decline in the vigor of the erections, and not unfrequently functional 
impotence results. This topic becomes the predominant idea, and the 
individual is haunted with a thousand fancies, of which " a loss of man- 
hood " is always the end of the series. In women, the menstrual func- 
tion is perverted. Sometimes there is amenorrhoea ; sometimes menor- 
rhagia. Some disease of the uterus is often the predominant idea with 
the female subjects of neurasthenia. 

Course, Duration, and Termination.— The author's view of the 
development and. course of neurasthenia is as follows : A man, origi- 
nally possessed of the neurotic type of constitution, has his nervous 
system rendered additionally impressible by the influences surround- 
ing him. Under the circumstances of this increased excitability of 
the nervous matter, its elements respond with abnormal readiness to 
the action of all stimuli, just as a motor or sensory nerve when in an 
irritable state is functionally readily responsive to stimulation. In a 
great preponderance of cases the initial disturbance is in the diges- 
tive organs, and thence reflex influences proceed to all parts of the 
nervous system. Sensations which in a normal mind would excite 
little attention, are in the case of these nervous subjects exaggerated 
into serious disturbances. The mental condition, after the gastro- 
intestinal disturbance, is the chief element in the morbid complexus. 
In no part of the complex of symptoms is the influence of the hys- 
terical or hypochondriacal condition more conspicuous than in the 
sexual state. The functional impotence, which is a constant symp- 
tom, arises for the most part out of the morbid fear of failure. The 
hebetude of mind and inaptitude for all kinds of mental work are large- 
ly dependent on the same morbid apprehension. The various cerebral 
symptoms which belong to dyspepsia awake in them the acutest ap- 
prehension of mental disease. The notion of such disease once started 
in the mind, every reflex sensation assumes the gravest proportions, 
and memory, and the power of attention, are apparently much im- 
paired, because the mind, absorbed in the study of the interminable 
bodily sensations, takes no cognizance of other impressions. Thus, 
gradually, in one of these nervous subjects, is the condition called neu- 
rasthenia evolved, from, it may be, the simplest kind of peripheric 
irritation, until no function remains undisturbed. In women a similar 
course of evolution is observed. If we substitute for the worries of 
business and pecuniary cares, the follies of fashion and the intermina- 
ble annoyances of housekeeping, we find that women of the neurotic 
type undergo the same kind of disturbances as men, and these result 
in them in a similar morbidity. Of course, the peculiarities of their 
sexual relations determine the direction taken by the morbid phe- 
nomena. In what mode it has developed, or whatever form the vaga- 
ries have assumed, the course of these cases is protracted. The con- 
dition of functional depression of the nervous system recognized, these 



NEURASTHENIA. 



711 



patients are subjected to the usual routine of tonics, stimulants, and 
nutrients. They are plied with iron, strychnine, good food, and out- 
door air and exercise is enjoined, but to little purpose. Shut up in 
darkened rooms, with some slave of mother or sister, these wretched 
invalids pursue their monotonous lives, content, in the midst of their 
fancies and their sufferings, with those attentions which feed their 
selfish invalidism. The male neurasthenic, hypochondriacal and yet 
hopeful of relief, abandons himself to the indulgence of his woes or 
occupies himself in the fruitless search for a cure which will accord 
with his own notions. 

Treatment. — Moral management and hygienic influences are very 
important. So long as the female neurasthenic is kept at home, the 
object of the solicitous attentions and suggestions of some slave of a 
mother or sister, little can be accomplished. Removed from the home 
influences, and subjected to an entirely new set of impressions, the first 
steps toward cure can then be taken. ISTo real change in the mental 
state of these subjects can be effected until the nutrition is put on a 
satisfactory footing. Systematic feeding is first to be attempted. One 
of two methods may be pursued. If hypersesthesia of the stomach is 
a pronounced feature, it is necessary to begin with a small amount of 
aliment at short intervals. It is under these circumstances that the 
milk-cure proves so valuable. If, however, the stomach permits the 
reception of suitable aliment, it is only necessary to carry out a proper 
system of diet, regulated by the nature of the digestive derangements. 
"Next in importance to a proper dietetic management is systematized 
exercise. It is almost certain that the best mode of resting the brain 
and mind is to divert the surplus blood into the muscular system. 
Walking is the best form of exercise, and this must be systematically 
carried out until the patient thus occupies a large part of his waking 
movements. It is impossible to exaggerate the value of this expedient 
in ordinary cases of neurasthenia. Mitchell's plan of treatment, re- 
ferred to under the preceding article, is well adapted to the cure of 
these cases. It is probable, however, that a considerable proportion 
relapse when returned to the influence of their former surroundings. 

General faradization, central galvanization, the electric bath, and 
sparks drawn from various parts, are of great value. The electrical 
treatment may be advantageously combined with massage, frictions 
of the whole surface with some animal fat, and regulated exercise. 
The methods of hydrotherapy, especially residence in some judiciously 
managed establishment in a mountainous region, is to be commended. 
Of the medicinal management, cod-liver oil and iron of the nutrient 
class and strychnine and picrotoxine of the spinal stimulant class may 
be advised. Arsenic and nux vomica are valuable as special remedies 
for feeble digestion. Phosphites and phosphates as nerve tonics are 
useful. It should not be forgotten that medicinal is strictly subordi- 
nated to the moral and hygienic management. 



712 



DISEASES OF THE NERVOUS SYSTEM. 



CATALEPSY. 

Definition. — Catalepsy is applied to a state with or without loss of 
consciousness, in which the cerebral functions are in a state of sus- 
pension, and the voluntary muscular system in a position of fixed 
rigidity. 

Pathogeny and Symptoms. — Catalepsy rarely occurs as an indepen- 
dent affection, and is usually associated with certain kinds of mental dis- 
order — with ecstasy, hysteria, and somnambulism. Young, impression- 
able, and nervous subjects are particularly liable to it. The attacks 
occur suddenly, and are not indicated beforehand by striking phe- 
nomena. It is true that prodromes may occur ; there may be changes 
in the feelings — sadness, unexpected gayety, a state of apprehension — 
~or actual pain, headache, and general muscular soreness may be felt, or 
vertigo, yawning, gaping, a condition of unrest, may come on ; but these 
sensations are neither necessary nor constant. The patient is attacked, 
in what position soever at the time, as if petrified, but there is no muscu- 
lar relaxation ; on the contrary, there is a state of tonic rigidity, the an- 
tagonistic muscular groups acting with equal tension. The conscious- 
ness is abolished in the sense that all exterior objects have vanished, 
and, although impressions may be received, they produce no reactions. 
While the mind is in abeyance, the muscular system is in a condition 
of tonic spasm, resisting passive motion and over which no voluntary 
control is exerted, and the muscles are suddenly fixed in the position 
in which they were when the seizure came on, as if set in stone. Al- 
though the muscles are not acted on by the will, they afterward sub- 
mit to passive motion, and remain in any position in which they are 
placed. But little resistance is then opposed to passive motion ; the 
members are perfectly flexible, and yet when fixed in a certain posi- 
tion remain immobile, and without trembling or vibrating. The limbs 
may be put into the most odd and uncomfortable attitudes, and main- 
tain them against gravity for some time, but the muscles at length 
begin to tremble and ultimately yield according to gravity. The 
appearance of the patient is very peculiar, sitting or standing immo- 
bile in a fixed attitude, staring straight forward and upward, the 
countenance pale and rigid, breathing scarcely perceptible, the pulse 
small and weak. On touching the conjunctiva, there are faint move- 
ments of the eyelids ; and, if articles of food are placed well back into 
the pharynx, swallowing is induced, but the organic like the voluntary 
movements are performed imperfectly. There may be entire abolition 
of the sensation of touch, of pain, and of reflex movements ; but in 
other cases the patients have a partial knowledge of events transpir- 
ing during the seizures, and in a few instances hyperaesthesia has been 
noticed. During the attack, the surface is cold, and the temperature 
falls. When the paroxysm ends, the patient suddenly rouses, takes a 



PARALYSIS AGITANS. 



713 



deep, sighing inspiration, yawns widely, and gapes loudly, as if wak- 
ing from a profound and protracted sleep. 

Course, Duration, and Termination. — The attacks of catalepsy vary 
in frequency and severity. They may last a few minutes, several 
hours, or for days. There is no regularity in the appearance of the 
attacks, and in the interval the patient may have good health, but usu- 
ally suffers from hysteria. After the first attacks, the patient may at 
once resume her ordinary occupation, but repeated recurrences set up 
a pathological condition of the nervous system, exhibited in the various 
phenomena of neurasthenia. As catalepsy is associated with certain 
forms of mental derangement, it is probable that its appearance may 
sometimes indicate the occurrence of such mental disorder. 

Treatment. — Only the protracted cases require attention during the 
paroxysm. Those cases which continue for days require alimentation 
by forced measures. The food may be placed well back into the 
pharynx, or liquids may be introduced through an (Esophageal tube 
passed by the nares. A few minims of amyl nitrite inhaled may suffice 
to stop the paroxysm, and the hypodermatic injection of morphine may 
be equally as effective. The usual antispasmodics — as asafoetida, vale- 
rian, camphor, turpentine — may be employed by the stomach or rectum. 
The most important measures are the prophylactic, to prevent the re- 
turn of the seizures by improving the tone of the nervous system. In 
anaemic cases, iron, the phosphates, and quinine, are the most appropri- 
ate remedies. Change of scene, agreeable variety, occupation affording 
the mind entertaining employment, are very conducive to the mental 
and moral stamina of such subjects. Electricity may be employed for 
the double purpose of arousing patients from the cataleptic state and 
for improving the tone of the nervous system. The methods of treat- 
ment applicable in hysteria are also useful in catalepsy. 

PARALYSIS AGITANS. 

Definition. — Paralysis agitans, or shaking palsy, is muscular tremor 
occurring with loss of power, the subject of the disease being advanced 
in life. 

Causes. — Although rarely seen under forty years of age, it does 
occur earlier, Duchenne having met with a well-marked example in a 
man of twenty. The two sexes are about equally affected. Heredity 
is apparently not concerned in its propagation. The principal causes, 
besides, probably, a peculiar state of the nervous system, are strong 
emotion, fright, grief, anxiety and similar moral impressions. Expos- 
ure to cold and dampness for a lengthened period, injury to periph- 
eral nerves of an irritative kind, are supposed to cause the disease 
sometimes. It is said to be more frequent in the Anglo-Saxon race 
(Charcot). 



714 



DISEASES OF THE NERVOUS SYSTEM. 



Pathological Anatomy. — In a certain proportion of cases, not defi- 
nite, however, no lesions of any kind have been discovered on post- 
moTtem examination. In other cases, induration (sclerosis) of the pons, 
medulla, tubercula quadrigemina, and lateral columns of the cervical 
cord, has been discovered, but Charcot, with justice, doubts the rela- 
tion of the lesions to the symptoms. In a third group, the lesions of 
disseminated sclerosis have been confounded with those of paralysis 
agitans. A consideration of these facts renders it evident that this 
disease is a neurosis, a functional disorder. 

Symptoms. — In the largest number of cases, paralysis agitans comes 
on slowly, a slight jerking occurring in a thumb, hand, or foot — in flex- 
ion of the thumb and finger, pronation and supination of the forearm. 
Any effort of the will, as grasping, writing, or walking, will stop the 
irregular motions. The trembling follows a certain order in its prog- 
ress from the point of beginning. If, for example, the right hand is 
first attacked by trembling, after some months or years, the right foot 
will become affected, then the left hand, next the left foot. Barely is 
the middle line crossed, but sometimes this occurs : the right hand 
first attacked, the next is the left foot. The tremors are often con- 
fined to one side of the body for a long time — ^hemiplegic type ; less 
frequently to both lower extremities — paraplegic type. In some excep- 
tional cases, a feeling of fatigue, or neuralgic pains, precede for some 
time the trembling, and are experienced in the same limb, which is 
subsequently attacked by tremors. Sometimes the disease sets in ab- 
ruptly, in consequence of some sudden shock, and may then affect one 
member or attack them all simultaneously. In what way soever the 
disease began, the symptoms of this initial period continue from one 
to three years, and then pass into the period of fixed intensity. When 
complete in its development, all the members invaded, the trembling 
becomes almost incessant, but it is not equally severe at all times. 
Mental emotion and exercise increase the trembling, and there are 
periods of exacerbation without any apparent reason, and sleep and 
chloroform narcosis suspend it. The trembling consists in successive 
jerks — muscular contraction and relaxation ; and in the hand some- 
times the thumb and fingers assume a position and movement like the 
rolling of a pill-mass. The head and neck are not affected, as a rule, 
but there are exceptions. The muscles of the face are motionless, the 
countenance fixed and stolid, the muscles of the jaws are unaffected, 
and there is no nystagmus or oscillations of the eyes. The tongue is 
somewhat trembling, the lips are compressed, and speech is slow, de- 
liberate, and jerky, as if the pronunciation of each word required a 
great effort. The muscles of the hand and of the neck, body and ex- 
tremities, assume a position of characteristic rigidity, preceded by 
pains and cramp, usually supposed to be rheumatic. The flexors are 
first and most severely affected. The patient assumes a characteristic 



PARALYSIS AGITAXS. 



Y15 



attitude, tlie body bent forward, the neck rigid, making the vertebra 
prominens still more prominent, the hands flexed and deformed, espe- 
cially in the fingers, and the whole presenting a strong similarity to 
the joint troubles of chronic rheumatism. Similar deformations occur 
in the lower extremities. It occasionally happens that rigidity and 
deformity occur with the first appearance of the trembling. Notwith- 
standing the trembling, the motor acts can be performed ; they are 
retarded rather than feeble (Charcot). The muscles are easily tired 
and the least effort causes a strons^ sense of fatio^ue. As a result of 
the peculiar disability of the muscles, the subjects of paralysis agi- 
tans have a peculiar gait. They rise slowly and are deliberate in start- 
ing, but, when under way, they go in a dog-trot with the head and 
body directed forward. Sometimes retropulsion occurs. Given a 
little jerk backward, they run backward until they fall. Besides the 
feeling of fatigue just mentioned, these patients suffer from a variety 
of evil sensations. One of the most distressing is the " fidgets," a feel- 
ing of unrest in the limbs associated with the impression of an irre- 
sistible necessity for movement. Sensations of pain, touch, and tem- 
perature are normal, but a subjective sensation of heat is often felt 
(Charcot). 

Course, Duration, and Termination.— This is a disease of very long 
duration — it may be thirty years. The first or formative stage lasts 
from one to three or four years ; the period of maximum intensity 
continues from two or three to twenty years. During this long time 
there is a progressive increase in the symptoms, until finally the 
patients are quite disabled, confined to the chair or to the couch. 
The muscles undergo more or less fatty change, and waste a good 
deal. At the terminal period very considerable prostration comes 
on, the urine and faeces are passed involuntarily, and the mind 
becomes cloudy and wanders. Just before death the trembling may 
cease entirely. 

Diagnosis. — Paralysis agitans and disseminated sclerosis were con- 
founded together, until Charcot pointed out the difference between 
them, showing that the tremors of the former are always present, 
while in the latter they occur only when purposive movements are 
undertaken. In senile trembling the head is chiefly affected, and the 
movement is merely that of trembling without the peculiar jerking of 
paralysis agitans ; in the former there are not paresis of the muscles, 
stiffness, deformity of the extremities, and the impulse to forward 
propulsion and to retropulsion, characteristic of the latter. Mercurial 
tremor occurs in those who are engaged in some occupation requiring 
exposure to the vapor of mercury, and it differs from paralysis agitans 
in being purposive, accompanied by troubles of coordination, defects 
of vision, by a grayish-blue line along the margin of the gums, by a 
fetid breath, and sometimes ptyalism. 



716 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — There are several remedies that moderate the trem- 
bling — hyoscy amine, according to Charcot, is the best, and in the au- 
thor's observation no remedy has acted so efficiently as this. Gelsemium 
sometimes is quite beneficial, but it must be given in quantity that will 
make an impression. To lessen the retrograde changes, the best results 
are obtained from the chloride of gold and sodium, with or without 
corrosive sublimate in small doses, given persistently, oxide or nitrate 
of silver and the lactophosphate of lime with arsenic, continued stead- 
ily for months at a time. Eulenberg has had good results from the 
hypodermatic injection of arsenic, and Ogle from extract of physo- 
stigma. Monobromide of camphor has appeared useful in some cases. 
The milder applications of hydrotherapy have done good in a few 
instances. From the variety and diversity of the remedies recom- 
mended, it is apparent that no plan of treatment has been satisfac- 
tory. There is a general agreement that the galvanic current is use- 
less. Eulenberg* says he has seen no good results from it ; Erb's and 
Rosenthal's experience is the same. 

CHOREA. 

Definition. — By chorea is meant a functional nervous disorder, char- 
acterized by defects of voluntary coordination, and by irregular spas- 
modic movements in certain groups of muscles. 

Causes. — A peculiar mobility and impressionability of the centers 
of coordination are, doubtless, transmitted by inheritance. The mode 
of life, education, and training may induce this unnatural mobility. 
The disease usually makes its appearance about the second dentition, 
or at the period of puberty. When the predisposition exists, various 
causes may excite the morbid complexus. Among the most important 
of the causative influences is rheumatism, or rheumatic endo- and exo- 
carditis. The closeness of the relation is variously stated. Professor 
See is at one extreme, for he finds in one hundred and twenty-eight 
cases of chorea sixty-four cases of acute rheumatism. Steiner, of 
Prague, is at the other extreme, for, in a series of two hundred and 
fifty cases of chorea, only four resulted from acute rheumatism. It is 
impossible to harmonize these observations. According to the author's 
experience, the proportion of rheumatism to chorea is about one to 
eight — much more than Steiner's, and less than See's. Intestinal 
worms, sexual abuses, amenorrhoea, anaemia, and strong moral emo- 
tions, are frequent exciting causes, and to these must be added preg- 
nancy. 

Pathological Anatomy. — There are no constant changes in the ana- 
tomical elements. As a large proportion of cases recover, it is proba- 
ble that the derangements are functional. As so many cases are com- 
* "Lehrbuch der funktionellen Nervenkrankheiten," op. cit., p. 711. 



CHOREA. 



717 



plicated by endocardial alterations, embolic obstruction of the minute 
vessels of the corpus striatum, or optic thalamus, has been proposed to 
account for the morbid phenomena, flughlings Jackson has espe- 
cially supported this view. As emboli have been discovered in some 
cases, it seems probable that this explanation is occasionally true. 
But various changes have been discovered : thus Meynert found 
changes in the cerebral cortex, and Elischer has recently detected nu- 
clear proliferation, thickening of the adventitia of the minute vessels, 
and hyperplasia of the neuroglia in the corpus striatum.* Localized 
softenings in various parts of the cerebro-spinal axis have been no- 
ticed, but no relation can be traced between such softenings and cho- 
rea, except those situated in the corpus striatum. 

Symptoms, — sudden terror has produced a fully developed 
chorea in an extremely nervous child, but usually the onset of the 
disease is gradual. At first the child appears to have adopted some 
trick or a grimace, or an ugly motion of the shoulder or arm. Then 
irregular jactitations become more common in the face and upper 
extremities. The choreic movements may be limited to one side of 
the body, when it is known as hemi-chorea, or to the upper or lower 
extremities. In a severe case all of the voluntary muscles of the body 
are engaged in choreic movements ; the muscles of the face are dis- 
torted into endless grimaces ; the eyes roll (nystagmus), and, the 
muscles acting unequally, there is strabismus ; the tongue is jerked 
about the mouth, so that speech is difficult or unintelligible, and is 
sucked into the throat with an audible smack ; the arms are troubled 
by endless jactitations, the fingers are twisted into all conceivable 
shapes, and writing, using the knife and fork, and holding any object 
are impossible ; walking is irregular, the legs catch each other or trip 
over objects ; breathing is spasmodic and sighing ; the heart's action 
is tumultuous, irregular, and apparently also choreic ; a soft-blowing 
murmur may be audible at the base, or a loud, churning systolic mur- 
mur, heard with greatest intensity in the mitral area. In the severest 
cases the patient can not remain in any position, but all the voluntary 
muscles are simultaneously engaged in the most violent and disorderly 
movements. The features are swollen and bloated ; blood is seen 
about the teeth ; the extremities are bruised and bleeding by the con- 
tinual knocking of bony prominences against the wall, the bed, or the 
floor. In the mild cases the jactitations are occasional and not severe, 
and cease during the night, permitting quiet repose. In the severe 
cases only snatches of sleep are obtained, the jerking of the muscles 
coming on after very short periods of quiet. In the severest cases the 
jactitations are incessant, and sleep is impossible. In all cases of cho- 
rea sleep is apt to be disturbed by unpleasant dreams, and somnambu- 

* " Ueber die Veranderungen in den peripheren Nerven und in Riickenmark bei Cho- 
rea Minor," Virchow's " Archiv," Ixi, p. 485. 



718 



DISEASES OF THE NERVOUS SYSTEM. 



lism is by no means uncommon. There is general exaltation of the 
senses of touch and pain, and the reflexes are increased. Tenderness 
of the spine, especially of the cervical and upper dorsal regions, is a 
constant symptom. Weakness or perversion of mind is observed in 
all decided cases, but usually impaired memory, stupidity, irritability, 
and morbid impulses have been observed. 

Course, Duration, and Termination.— The course of chorea is chronic 
and continuous, and the duration of ordinary >cases is from one to three 
months. Although regarded as self -limited and tending to spontaneous 
recovery in two or three weeks by some authorities, it is really much 
influenced as to its course and duration by appropriate treatment. It 
may continue for a number of months, for years in fact, but this is 
excessively rare. Exacerbations and relapses are very common. Those 
having attacks at about seven years of age are apt to experience seiz- 
ures up to puberty. If occurring in the first pregnancy, it is apt to 
occur in subsequent pregnancies. The most intractable cases, accord- 
ing to the author's experience, have been those of the first pregnancy. 
Although the termination is usually in health, death may result from 
the exhaustion due to the incessant jactitations, want of food, and loss 
of sleep. The existence of pregnancy is a serious complication, for, 
besides the danger of miscarriage, the severity of the disease induces 
rapid exhaustion. Jaccoud collected thirty-one cases of the chorea 
of pregnancy, and of these four died. After delivery the convulsions 
cease, but very rarely before delivery. 

Diagnosis. — Chorea is accompanied by such pronounced symptoms 
that it can hardly be mistaken for any other disease as it occurs in chil- 
dren. It may be confounded with disseminated sclerosis which appears 
in young subjects, and which has for a prominent symptom muscular 
tremor, but the tremors are perceived only on intentional movements, 
and cease when the muscles are at rest. Furthermore, this disease is 
accompanied by pareses of the muscles and the rigidity of extension, 
and often sets in with an apoplectic attack and other formidable symp- 
toms ; and its course and behavior are so different in all other respects 
from the tremor, that the least attention ought to prevent error. Pa- 
ralysis agitans differs from chorea in the age of the subject, the deform- 
ity of the hands, the muscular rigidity, the shape assumed by the 
spine, and the character of the gait, and in the subsequent course and 
termination. 

Treatment. — Excellent results have been obtained by a simple hy- 
gienic treatment — by confinement to bed in a darkened and quiet 
room, and careful but generous alimentation. As moral causes, excite- 
ment and bad hygiene, are very influential in causing the disease, sup- 
plying the patients with the opposite conditions ought to effect im- 
provement. Treated in this way, it was ascertained at Guy's Hospital 
that chorea has a tendency to spontaneous cure in two or three weeks. 



WRITER'S CRAMP. 



719 



It is important to give to choreic subjects sound sleep — to suspend the 
jactitations during ten hours. This is best accomplished by the com- 
bined use of morphine and chloral. A generous diet should be direct- 
ed, and the utmost quiet and repose enjoined. Any eccentric irritation, 
as worms in the intestines, impacted f seces, elongated prepuce, or sexual 
excess, should be corrected. Anaemia requires the free administration 
of iron, lactophosphate of lime, and strychnine. The remedies to stop 
the choreic movements consist of the mineral tonic group — arsenic, 
the zinc preparations, ammoniated copper, and iron ; of the vegetable 
paralysant group, as succus conii, gelsemium, physostigma ; and the 
anodyne group, as opium, chloroform, chloral, bromide of potassium. 
Of the mineral tonic remedies the best results are obtained from arsenic, 
of which very large doses are easily borne. In some obstinate cases 
the hypodermatic injection of arsenic has achieved successes. In the 
most violent cases, chloroform may be indispensable to give even a few 
minutes' repose. In these violent cases, enormous, almost incredible 
doses of morphine were given by Trousseau with advantage. Mild 
cases are benefited by ether-spray directed against the spine for a few 
minutes every day. Galvanization is also serviceable. A stabile cur- 
rent, not too strong, should be applied to the spine and to the princi- 
pal bundles of spinal nerves. Hydrotherapy, in the form of a wet pack, 
and douche to the spine, has been useful in many cases. 



WRITER'S CRAMP. 

Definition. — Writer^s cramp is a faulty term, but no really better 
designation has been proposed. It is intended to express the idea of a 
muscular disability produced by overuse in a strained position of cer- 
tain muscles. It is called writer's cramp because so many cases have 
arisen from this employment. The same disability occurs to pianists, 
to seamstresses, and some other employments requiring the continuous 
use of the same group of muscles. 

Pathogeny and Symptoms. — There is not an actual condition of 
cramp ; the affected muscles are not paralyzed, and are equal to all 
other work, except the particular duty in which they acquired the dis- 
ability. Duchenne well expresses it when he says there is an impo- 
tence in respect to the particular position and movements involved in 
writing. There is no disorder of intelligence, no lack of ideas, and 
the motorial apparatus is intact, but the muscles, so long and constant- 
ly employed in the prehension of the pen, the poising of the hand and 
forearm, and in the movement of the pen (Poore *), become unequal to 
the task. The growth of the disability is slow. Fatigue in the much 
used muscles, pain in the forearm, in the wrist, and in the hand, are 



* "The Practitioner" (London), 18Y9. 



720 



DISEASES OF THE NERVOUS SYSTEM. 



experienced. So strong is the sense of fatigue, and it may be pain in 
tlie arm, tliat rest is often taken ; the arm is steadied, and the pen is 
seized with a firmer grip. Other muscles are called into action, and 
great efforts are made to relieve the fatigued muscles by writing with 
the whole arm. The writing changes its character and becomes irreg- 
ular ; the muscles of the first three fingers, after a time, are given to 
fibrillary trembling. Finally writing becomes impossible ; the pen is 
taken up, a strong effort of the will tries to force the muscles to the 
task, but they obstinately refuse to execute the necessary movements. 
In a perfectly normal state, writing is so constantly and for such a long 
period carried on, that the supervision of the higher centers over the 
muscular movements ceases to be exercised : in other words, the act of 
writing becomes largely automatic. When such a muscular disability 
occurs, the attention must be again directed to the act, and then a new 
element of discord is introduced. Besides fibrillary trembling, a con- 
dition of tonic spasm seizes the muscles of the thumb and the flexors 
of the fingers. These involuntary contractions or spasms of the mus- 
cles sometimes also involve the extensors, and thus a condition of 
ataxia results. There is still another group of cases in which a marked 
paresis or weakness of the flexors of the thumb and fingers takes place, 
and fibrillary trembling frequently coincides with the weakness. This 
group is called the paralytic form. There is still another group in 
which the flexors and extensors are occupied by cramps, there is no 
trembling, no sense of fatigue, and the sensibility is intact. In the 
paralytic group the electro-sensibility and the electro-contractility are 
reduced ; in the spasmodic group, the electro-sensibility and contrac- 
tility are either exaggerated or normal. 

Course, Duration, and Termination. — The course of writer's cramp 
is very chronic and the duration indefinite. It is more often than 
is supposed the precursor of more serious ailments of the nervous 
system. If, with the first symptoms, entire rest be given to the 
affected member, a cure may be readily effected ; but, when the 
disability is complete, the prognosis as to cure is very gloomy. If 
it be true, as the author's observation has led him to conclude, that 
writer's cramp is often followed by other nervous diseases, no case 
is without importance, and the management should include instruc- 
tions as to manner of life and regimen, to avoid future complica- 
tions. 

Treatment. — As soon as the symptoms of writer's cramp become 
manifest, writing should be relinquished immediately, and the muscles 
be given rest for several months. Rest may remove all the symptoms, 
and subsequently moderation in the amount of writing and giving 
sufficient intervals of rest will entirely obviate the tendency to cramp 
or paresis. Much attention should be given to the position of the 
fingers, and to the amount of effort necessary. A large pen-holder 



TETANUS. 



721 



and an easy, unembarrassed manner of grasping the pen are of much 
importance. When the case is complete, and writing becomes impossi- 
ble, a cure is not to be hoped for ; but such amelioration may be effected 
as to permit a very little daily use of the hand in writing. There are 
two local remedies of real value — galvanism and massage. A current 
from ten to fifteen of Siemens and Halske's elements should be passed 
daily for a few minutes through the affected muscles. If spasm and 
fatigue are the conditions of the muscles, a stabile current is to be pre- 
ferred ; if the muscles are weak, a labile current should be used. The 
forearm, the muscles of the thumb, and the interossei should be gently 
rubbed and kneaded for a few minutes previously to the application 
of electricity. If the general health is depressed, good effects are ob- 
tained from strychnine ; but this agent does harm if the nervous sys- 
tem is excitable and the circulation active. The phosphates, quinine, 
and cod-liver oil, should be prescribed if the health is poor. 



TETANUS. 

Definition. — By tetanus is meant a disease characterized by parox- 
ysmal tonic contractions of the voluntary muscles, and due to an exal- 
tation of the reflex function of the spinal cord. 

Causes. — Tetanus may be produced by intrinsic or central lesions 
and extrinsic or peripheral lesions. The latter are more important than 
the former. As the best example of a tetanic condition due to cen- 
tric causes may be mentioned the action of those agents which increase 
the reflex excitability of the spinal cord, namely, strychnia, brucia, and 
thebaia. The extrinsic causes are wounds and injuries of various 
kinds, especially those involving nerves, many of which are insignifi- 
cant — for example, the prick of a needle, the extraction of a tooth, per- 
forating the ears for ear-rings, or bleeding — each of which has caused 
tetanus. Internal traumatic injuries may produce the same result. 
Tetanus has followed parturition and uterine diseases ; and the so- 
called idiopathic tetanus has supervened upon inflammatory exuda- 
tions, involving the pneumogastric or phrenic nerves. The severity 
of the injury bears no relation to the frequency or violence of the 
attacks. When a wound is cicatrizing, tetanus is more apt to occur, 
especially if the cicatrix is so situated as to compress a nerve. The 
situation of a wound has more influence — those of the extremities hav- 
ing the greatest effect. Trismus neonatorum, tetanus of the new- 
born, occurs usually from the fifth to the twelfth day, and is attributed 
to section of the funis and a subsequent inflammation. Tetanus also 
succeeds to circumcision. Much influence is ascribed to cold by some 
writers. It is probably true that wounded men, exposed to cold, are 
more liable to the disease. The free use of cold water as a dressing 
for wounds, during the rebellion, was responsible for many cases, it is 



722 



DISEASES OF THE NERVOUS SYSTEM. 



supposed by competent judges. On the other hand, tetanus is a com- 
mon malady in tropical countries. 

Pathological Anatomy. — The changes occurring in tetanus are 
found in various parts of the cord, but chiefly in the medulla oblongata, 
in the lumbar region, in the gray substance around the central canal, 
and in the anterior horns. Very considerable dilatation of the vessels 
is always found. Exudation of a semi-fluid, colloid substance, hyper- 
plasia of the neuroglia, and abundant nuclear proliferation in the gray 
matter, have been observed in the more recent microscopical investi- 
gations. 

Symptoms. — The onset of the disease varies according to the cause. 
When due to a wound, there are changes in its character as the disease 
is about to develop : the cicatrization ceases, the suppuration presents 
a different aspect, the wound becomes irritable, tender, and red, and 
pains shoot along toward the body. When caused by cold, there is 
chilliness, followed by fever, and stiffness of the neck is felt. The 
first manifestation of the tetanic paroxysm is, in a great majority of 
cases, in the motor branches of the fifth, which innervate the masseters 
and internal pterygoids, and the jaws are set in a condition of rigidity. 
To this tetanic fixation of the jaw is applied the term trismus. The 
attempt to swallow excites cramp of the pharynx, and is therefore 
difficult and painful. Next, the post-cervical muscles become rigid, 
and the head is held back. The muscles of the face now take a fixed 
position, the lips are retracted, exposing the teeth ; the brow is cor- 
rugated, giving to the countenance a mixed expression of anguish and 
laughter — the risus sardonicus. The muscular rigidity now extends 
to the trunk and extremities, and hence the whole body, while helpless, 
is immovable and rigid. As the spinal muscles are more tense and 
more powerfully acted on, the body is bent, and may rest only on the 
occiput and heels. This position is entitled opisthotonos. Less fre- 
quently, the body is bent in the opposite direction, or forward — a po- 
sition known as emprosthotonos. Still more rarely the inclination is 
lateral, or pleurosthotonos. The condition of excitation is not the same 
all along the spinal canal, for we find that the flexors of the upper 
and the extensors of the lower extremities are comparatively more 
active. In the beginning of the attack, the rigidity is not constant, 
does not affect all the muscles equally, and may pass from one to 
another group. There are remissions also at first, during which there 
may be complete relaxation. But the paroxysms become more fre- 
quent and severe, and are presently excited by the slightest movement. 
So exquisitely excitable is the reflex faculty, that the least possible 
peripheral impression brings on a spasm — a mere touch, a current of 
air, the reflection from a mirror or surface of water, will excite it. 
At the moment of the spasm a sudden tonic contraction seizes all of 
the voluntary muscles, the face is horribly distorted, the spine is bent, 



TETANUS. 



723 



the body resting on the head and heels, the abdomen retracted, respi- 
ration suspended, the feet incurved and extended, the hands violently 
clinched and drawn in with the forearms toward the body. During 
the convulsion a severe pain is felt at the epigastrium, and extends 
through to the back. The muscles so violently acted on are very pain- 
ful, and even rupture of fibers, sometimes of a muscle, may take place. 
The paroxysm soon reaches its maximum and then subsides, and dur- 
ing the interval between them the patient breathes more easily, and is 
able to swallow a little. The frequency with which the paroxysms 
come on, their violence and duration, furnish the measure of the im- 
portance of the case. Some sleep may be obtained in the interval 
between the paroxysms, but on awaking the attacks of spasm are re- 
sumed, and in severe cases sleep is entirely prevented. Meanwhile, 
the mental powers are unimpaired, and sensibility and the special 
senses remain normal. In a few instances diminution of sensibility 
has been noted. As muscular activity is a great source of animal 
heat, it is not surprising that in this disease there should be rise of 
temperature. The fever does not pursue any special type, but at 
death it may attain to 104° or 105° Fahr., and rise even higher for an 
hour or two after death. Profuse sweats also occur. Respiration 
during the spasms is carried on by the diaphragm only, and the pulse 
becomes hard and very rapid. The voice is harsh, guttural, and some- 
times speech is unintelligible. The mouth is dry, the saliva viscid, 
deglutition almost impossible, and constipation is the rule. The 
urine is normal, or scanty, usually alkaline, and sometimes contains 
sugar. 

Course, Duration, and Termination. — The course of tetanus may 
be very acute, or more protracted, when it is known as chronic tetanus. 
In the acute form an early termination is caused by tetanic fixation of 
the muscles of respiration. In the chronic form the intervals between 
the paroxysms are longer ; the patient has an opportunity to obtain 
some sleep and to take food. In the tetanus of the new-born, and in 
toxic tetanus, the duration is shorter than in the traumatic, the parox- 
ysms succeed each other rapidly, and death occurs in asphyxia. Idio- 
pathic tetanus is not so violent, as a rule, and the prognosis is hence 
more favorable. Traumatic tetanus is always serious, but the case 
may be regarded as more favorable when the intervals between the 
paroxysms are long enough to permit sleep and alimentation, and the 
paroxysms are less dangerous to respiration. The case is still more 
favorable if, after the second day, there is no increase in the number 
and severity of the paroxysms. 

Diagnosis. — Tetanus is distinguished from strychnine-poisoning by 
the sudden onset and quick termination of the latter, and by the pres- 
ence of a wound or some other cause of the seizure. In spinal menin- 
gitis there are tonic spasms of the muscles, but the rigidity is not 



724: 



DISEASES OF THE NERVOUS SYSTEM. 



paroxysmal, and there are no intervals of entire cessation of the mor- 
bid action ; there is not the great reflex excitability of tetanus and 
the occurrence of cramps on slight irritation peculiar to that disease, 
and in spinal meningitis the tonic rigidity is succeeded by paralysis. 
Hydrophobia is very similar to tetanus, but it develops more slowly ; 
there is a special antipathy to water and inability to take it when other 
articles may be swallowed, and a peculiar hawking noise is made, to 
dislodge a little viscid secretion from the throat, peculiar to this dis- 
ease. Trismus may be limited to the muscles of mastication, and may 
be produced by colds and exposure, but it is confined to these muscles 
and does not become generalized. Those cases occurring in the course 
of cerebral disease are also diagnosticated by the symptoms of such 
diseases, which have no relation to tetanus. 

Treatment. — Whenever an obvious cause exists it must be removed. 
If a wound, splinters of bone and foreign bodies should be searched 
for ; if a cicatrix, it should be dissected out ; if an injured nerve, it 
should be divided. The remedies which have been most successful are 
those which diminish the reflex function of the spinal cord. Bromide 
of potassium seems to have been the most successful agent thus far 
employed. It must be given in very large doses — from one to two 
drachms every four hours, until the spasms are decidedly diminished, 
when the quantity may be somewhat reduced. Given early, and the 
effect maintained until the spasms cease, it must be regarded as the 
best remedy in view of the large proportion of cures. Next to the 
bromide is curara, which acts on the end-organs of the nerves and on 
the reflex faculty. This must be given hypodermatically, and the 
effect produced must be the guide. As curara is a very uncertain sub- 
stance in its composition, the dose necessary can only be determined 
by trial, but, inasmuch as one eighth of a grain has been administered 
at a dose, it will be prudent to commence with one fortieth of a grain, 
and increase it until some effect on the spasms has been caused. Nico- 
tine has similar properties and powers, and has been used hypoder- 
matically in tetanus and in strychnine-poisoning with success. The 
author has seen a very severe case of traumatic tetanus treated suc- 
cessfully with the wine of tobacco. Physostigma and eserine have 
been now employed in a large number of cases and with excellent 
results. Eserine can be given subcutaneously, beginning at one six- 
tieth of a grain and increasing it until some effect is produced on the 
spasms. Cannabis Indica has also arrested some cases of tetanus, 
and is a very promising remedy. Recently urethane has been proved 
to have the most complete antagonism to strychnine, and is strongly 
recommended as a remedy for tetanus. The spinal ice-bag and the 
continuous current have proved palliative. Warm baths and the vapor- 
bath have given comfort, and have exerted a temporary influence over 
the spasms. An estimate of the value of a remedy is much affected 
by the period at which it is administered, for the longer the case has 



NEURITIS. 



725 



lasted the more hopeful. The nutrition of cases of tetanus is highly 
important, and from the beginning they should be carefully fed. 
Noises and excitement, every form of peripheric irritation, and emo- 
tion of all kinds, should be excluded. As there is strong temptation 
to use ether and chloroform freely because of the relief they afford, 
the author desires to caution his readers, because of the injury so 
often done by them. 



DISEASES OE THE PERIPHERAL NERYES. 



NEURITIS. 

Definition. — The word neuritis signifies inflammation of a nerve, 
but there are several distinctive maladies which may be grouped un- 
der this designation. There is a simple neuritis, in which one or 
more nerves may be affected by some local cause, usually trauma, and 
this may be either an acute or chronic inflammation. Toxic neuritis 
is that form of the disease induced by some poison introduced from 
without, as lead, copper, arsenic, etc. Diathetic neuritis arises from 
some systemic condition, such as rheumatism, gout, syphilis, etc., or 
it is due to the blood changes in typhoid, diphtheria, scarlet fever, 
and similar diseases. Again, neuritis, in consequence of conditions not 
well understood, manifests a tendency to spread from its point of 
origin and involve many other nerve trunks, whence we have ascend- 
ing neuritis^ multiple neuritis^ and progressive multipde neuritis. 

Causes. — The influences affecting the inflamed nerves are necessa- 
rily various. Simple neuritis is produced by wounds, injuries, and 
by the transference of the morbid action from a neighboring inflamed 
tissue. Thus, intercostal neuritis is caused by an adjacent pleuritis, 
or tuberculosis of the lung ; sciatica, by a pelvic abscess or inflamed 
haemorrhoids ; and caries of bone may involve a nerve or plexus of 
nerves in the vicinity. As neuritis may occur in various nerve trunks 
simultaneously, and without apparent cause, there is, probably, a pe- 
culiar type of nervous system in which such an action is prone to 
take place. It is probable, also, that the occurrence of neuritis, in 
cases of fever and septic diseases, is due to the constitutional type of 
the affected individual, for such an accident is quite unusual. The 
special causes which originate and maintain progressive multiple neu- 
ritis are quite unknown. 

Pathological Anatomy. — The first step in the process is hyperae- 
mia : exudation takes place into the nerve, which becomes softened 
and ultimately breaks down into a diffluent mass. Migration of white 
corpuscles takes place into the neurilemma, an exudation partly serous, 
partly fibrinous, and minute extravasations occur between the fasciculi. 



Y26 



DISEASES OF THE NERYOUS SYSTEM. 



and then suppuration and softening result. Recovery may ensue be- 
fore disintegration of the nerve elements is produced. The fibrinous 
exudation undergoes the usual changes — the watery part is absorbed, 
the solid matters and the corpuscular elements become fatty and are 
then taken up, and health is restored. In the chronic form of neuritis 
the change is less toward pus-formation and softening, and more to 
hyperplasia of the connective tissue. The nerve forms intimate adhe- 
sions to the neighboring connective tissue, the medulla undergoes fatty 
degeneration, and the nerve-fibers and axis-cylinder atrophy. These 
changes may occur in particular parts of the nerve, giving it a knobbed 
appearance, whence the term neuritis nodosa. It is important to 
note that when inflammation occurs in a nerve it may extend from the 
point first diseased upward (neuritis ascendens), or downward [neuri- 
tis descendens). By the extension of an ascending neuritis the S23inal 
cord may be ultimately affected. 

Symptoms. — If an important nerve or plexus is inflamed, there may 
be some fever preceded by chilliness, or a decided chill, headache, and 
general muscular soreness ; but the most pronounced symptom is pain 
in the nerve, not only at the point inflamed, but spreading thence over 
the peripheral distribution. The pain is of a very distressing kind ; 
it is a burning, tingling, tearing, and intense pain, and is increased by 
motion or pressure. There is a high degree of sensitiveness in the 
region of the inflammation ; numbness and formication are mixed with 
the pain, and ultimately the parts supplied by the nerve become anaes- 
thetic, which means destruction of the nerve, or pressure sufficient to 
prevent the transmission of impulses. If the nerve inflamed be motor 
in function as well as sensory, there will occur spasmodic contractions 
and cramps in the muscles to which the nerve is distributed ; then will 
follow paresis, and ultimately paralysis, if the nerve is compressed or 
destroyed. Besides the general fever accompanying the neuritis, there 
is a local elevation of temperature in all the region of distribution of 
the nerve. In the chronic form there do not occur the constitutional 
symptoms which are present in the acute form, but pain and other 
symptoms of sensory irritation, and cramps and other symptoms of 
motor irritation, do appear. Besides the effects of neuritis within the 
distribution of the affected nerve, various reflex and radiation phe- 
nomena are manifest. Pain is felt in all the branches of the same 
plexus, and cramp in the muscles innervated from the same source. 
Wasting and degeneration of the muscles and anaesthesia of the parts 
innervated by the affected nerve are results of the neuritis. Various 
trophic disturbances are also caused. Various forms of cutaneous 
eruptions appear — herpes, eczema, and " glossy skin " ; the nails be- 
come clubbed, the hair falls out, and the joints swell and change in 
structure. The affected nerve in the stage of irritation responds more 
readily to electric currents ; if the nerve is simply compressed the 
muscles may respond normally, yet if destroyed there will be no reac- 



NEURITIS. 



727 



tion to faradic stimulation, but to the galvanic ; in other words, after 
the increased excitability to electric stimulation, the characteristic re- 
actions of degeneration will come on. 

Progressive Multiple Neuritis. — Simple acute or chronic neuritis 
manifests a tendency to extend from the point of original mischief 
upward. In progressive multiple neuritis, this tendency to extension 
upward is the most distinctive characteristic of the malady. It is also 
widely diffused, numerous important nerve-trunks becoming simulta- 
neously affected. It is either occurring more frequently than for- 
merly, or it is a comparatively new disease. It may be that more 
exact knowledge renders its differentiation more certain. Since 
Dumenil published his observations, the first that had been made, 
various cases have been reported. After Dumenil, examples of the 
disease, with comments, were published by Eichhorst,* Jaffroy,f and 
others. Last year Dr. Webber, of Boston, published an important 
memoir, based on cases he had observed. Some cases have been en- 
countered by the author, and he has now a very complete example 
in his charge. It is probable that this disease, sometimes, has been 
mistaken for progressive muscular atrophy. 

Progressive multiple neuritis is an acute affection, marked at the 
onset by chilliness, fever, and tingling pains, with coldness of the 
hands and feet. As in all acute inflammatory affections of the nervous 
system, there are two distinct groups of symptoms : those of the first 
stage, significant of irritation ; those of the second stage, indicating 
depression. The irritation symptoms are due to the congestion of the 
nerve sheaths and trunks, and the beginning exudation ; the anatom- 
ical elements as yet remaining intact, respond to the irritation caused 
by new materials in the tissues. As compound nerves are those 
affected, obviously the symptoms must include both sensibility and 
motility, pain and spasm being the result. Tingling, burning, and 
lightning-like strokes in the paths of distribution of the nerve-trunks 
of the extremities are experienced. The ulnar nerve and its terminals 
appear to be specially affected. The nerves, the seat of pain, are 
found to be very tender on pressure, and the intramuscular filaments 
being also affected, any muscular movement causes suffering, which 
may be so severe that the patient maintains as complete repose as pos- 
sible. During this period of heightened sensibility there occur, also, 
motor phenomena of a corresponding character. With the onset of 
the irritation of the motor nerve-fibers, the muscles innervated by 
them become spastic, tense, and disposed to contract, or may be seized 
with spasms. The reflexes are heightened, and the responses to stimu- 
lation assume the character of tonic cramp. The electrical reactions 
correspond ; there is an increased readiness of response on the part of 

* Yirchow's " Archiv," vol. Ixix. " Neuritis Acuta Progressiva." 
f "Arch, de Physiol. Norm, et Path.," 1879, p. 1^2. "Nevrite parenchymateuse, 
spontanee, generalisee ou particlle." 



728 



DISEASES OF THE NERVOUS SYSTEM. 



the sensory nerves witli pain, and of the motor nerves with tetanized 
contraction. But the morbid action continuing, in a short time the 
increased sensibility is succeeded by anaesthesia and analgesia. The 
tactile sense is blunted so that the points of the sesthesiometer are only 
recognized when widely separated. The senses of pressure, of tem- 
perature, and of locality become equally blunted. The muscles grow 
weak, paretic, and are presently paralyzed, and with the paralysis rapid 
wasting ensues. The atrophic degeneration begins in the small mus- 
cles of the hand, and thence extends to the forearm, and in these parts 
it continues more pronounced than elsewhere, but all the paralyzed 
muscles undergo more or less change, and exhibit finally the charac- 
teristic reactions of degeneration. The cutaneous and tendon reflexes 
are also abolished. The skin, nails, and hair undergo atrophic changes. 

The acute symptoms last from a few days to a few weeks, and 
during this period the sensory and motor disturbances become well 
defined. The disease then assumes a chronic character, and continues 
on from two months to two years. In the favorable cases, the disease 
does not diffuse so widely, the paralysis is less complete, and the trophic 
changes are not so pronounced. In the most favorable cases, there 
may be permanent wasting and deformity of the muscles innervated 
by the ulnar nerve, the little and ring finger remaining contracted, 
shriveled, and almost useless, and the hypothenar eminence shrunken. 
In the unfavorable cases, the chief nerve-trunks of the extremities are 
invaded, the nerve-roots and the spinal cord become diseased, and the 
four members are disabled. An extension of the neuritis may take 
place to the medulla with the production of the characteristic results 
in the respiratory and circulatory systems, or the patient may be cut 
off by an intercurrent malady, as pleuritis, pneumonia, or phthisis. 

The prognosis as regards danger to life is favorable, as but few 
cases die. Protracted suffering, paralyses, and deformity may be 
looked for in the more chronic cases, and recovery, when it ensues, is 
apt to be clouded by the disabilities. 

Course, Duration, and Termination. — The acute form is necessarily 
of short duration. Recovery ensues, permanent disability results, or 
it becomes chronic. Restoration is possible only before disintegration 
of the nerve. The chronic form has no fixed duration. Recovery is 
more likely to ensue when there has occurred a simple injury or exte- 
rior pressure, which may be removed, than when an idiopathic or rheu- 
matic inflammation has taken place. The latter are apt to become 
very protracted, to have periods of remission and exacerbation, thus 
continuing for years. The prognosis will be largely determined by 
the character of the symptoms — pain and muscular cramps, indicating 
the stage of irritation — anaesthesia and paralysis, the stage of injury 
to the nerve-trunk. Very important in this connection is the electrical 
diagnosis ; for, if the irritability of the muscles to the farad ic current 
is preserved, the nerves are still intact, and vice versa. As neuritis 



ATROPHY OF THE NERVES. 



729 



manifests a strong tendency to ascend, in the course of the malady 
secondary degeneration of the spinal cord may ultimately take 
place.* 

Diagnosis. — The differentiation of neuritis from myalgia is effected 
by reference to the points of tenderness — to the symptoms of irrita- 
tion, succeeded by those of depression of a nerve ; from neuralgia, by 
the fever in the acute form, by the changes in the trophic condition of 
the skin, and by the state of the muscles and the reactions of the fara- 
dic current. 

Treatment. — The various causes of the disease must be removed. 
Here surgical treatment of wounds and injuries may be invaluable. 
In acute cases of plethoric and vigorous subjects, leeches should be 
applied along the course of the nerve. A full dose of morphine and 
quinine should at once be given (gr. ss. — gr. xv for an adult), and the 
tincture of aconite-root (two drops every two hours) ; or morphine may 
be giv^en subcutaneously if the pain is severe. In the chronic cases, 
the most effective remedies are galvanism and the hypodermatic in- 
jection of morphine. The positive pole is placed on the tender spot 
or spots, and the negative at the peripheral expansion, daily applica- 
tion of a few minutes' duration being made. A succession of flying- 
blisters, or the electric brush, or the oleate of morphine, may be used 
locally, the iodide of potassium, cclchicum, etc., internally in the more 
obstinate cases. 

ATROPHY OF THE NERVES. 

Pathogeny. — Atrophy of the nerves arises from various causes: 
from central diseases, of which examples are afforded by posterior 
spinal sclerosis, progressive bulbar paralysis, infantile paralysis, etc.; 
from peripheric lesions, as injuries by wounds, or compression of 
tumors, etc. 

Symptoms. — The disturbances by atrophy are part of the morbid 
complexus of various affections, and consist in depression of func- 
tion, wasting of the muscles, paralysis, and, as regards the sensory 
nerves, anaesthesia. 

NEURALGIA— NEURALGIA OF THE FIFTH NERVE. 

Definition. — Neuralgia of the fifth nerve has received various desig- 
nations — prosopalgia^ tic-doiiloureiix^ FothergilVs disease, etc. 

Causes. — The causes of tic-douloureux may be comprehended in 
three groups — constitutional, immediate, and remote. Heredity is an 
important factor, since this disease is one of numerous maladies possi- 
ble to the neurotic temperament or disposition. It is not unfrequently 
associated with epilepsy, as Trousseau was the first to point out. It 

* Yulpian, "Archives de Physiologie," vol. ii, 1869, p. 221, "Experiences relatives ^ 
la pathogenie des atrophies secondaires de la moelle epiniere." 



730 



DISEASES OF THE NERVOUS SYSTEM. 



may occur at any age, but is more frequent from the middle period, on, 
and in women at the climacteric period. Anstie * insists on the impor- 
tance of the degenerative changes of age as causes of the origin and 
of the intractable character of some cases. The female sex seem more 
susceptible than males. Certain dyscrasise, as lead, syphilis, malaria, 
etc., are undoubtedly causative. Anaemia, amenorrhoea, a depressed 
state of the bodily functions, the exhaustion induced by excesses in 
venery, gout, and rheumatism, are predisposing causes. Psychical im- 
pressions, especially if depressing, are held by Anstie to be causative. 
Changes in the structure of the nerve, tumors, exostoses, and aneur- 
isms, caries of the bones, periostitis, gummata, etc., are among the 
immediate causes. Decayed teeth, indigestion, worms, constipation, 
menstrual derangements, etc., are among the remote causes. 

Pathological Anatomy. — The changes of neuritis have been some- 
times observed in the trunk of the nerve and in the ganglion of Gasser. 
More frequently no changes have been noted. The nerve is more 
often affected by exterior pressure. In one of the most severe cases 
ever witnessed by the author, the nerve was impinged on by an aneu- 
rism of the basilar artery, and was very much thickened and soft- 
ened. Probably the most frequent pathological condition is the pres- 
sure of an exostosis, or other form of tumor, on the trunk of the nerve 
within the cranium. 

Symptoms. — The usual history is that of gradually increasing pain 
in the face or teeth. At first the attacks are regarded as merely tooth- 
ache, and tooth after tooth is extracted in the vain hope of finding the 
painful one. It may be months before the pain assumes the charac- 
teristic expression. Then distinct paroxysms occur, than which nothing 
can be more horrible. A sudden pain pierces the face, the muscles of 
that side are convulsed, the eye is injected, and the tears flow- — the 
patient starts up with a terrible groan, rubs the cheek vigorously, 
wrings his hands, cries out in the extremity of his agony, rushes about 
his apartment, and it may be suddenly the pain ceases and the parox- 
ysm is over, or it gradually subsides. At first these attacks may be 
weeks, even months apart, but after a time they get more numerous. 
In the interval between the seizures there may be entire freedom from 
pain, but in many cases there is nearly constant soreness, or aching, 
in the jaws or eyes. When the pain is wholly paroxysmal, the attacks 
are more frequent, and, in the interval between them, the patient 
experiences a tense feeling in the affected region as if the slightest 
movement on his part would excite a paroxysm. When this sensation 
comes on, he durst not move, he can not be spoken to, every muscle is 
in a state of tension and immovable, he hardly breathes, he looks 
straight before him in an attitude of suspense and apprehension. In 



* "Neuralgia and its Counterfeits," London, 18*71, p. 31. 



NEURALGIA. 



Y31 



spite of the dreadful energy of tlie self-control, his effort often fails, 
the pain comes on with a lightning-stroke, his teeth set hard, the face 
pales, the pupil dilates ; then he abandons himself to his suffering, he 
starts up with a groan, and repeats the rubbing, the wringing of hands, 
the cries, etc. Ultimately so sensitive become the peripheral nerves, 
that the slightest touch, a breath of air, excites the paroxysm, and the 
attempt to take food produces the most frightful torments, the face is 
thrown into spasms, tears run down the cheeks, and the patient utters 
horrible groans. So dreadful is the aspect of this suffering, that these 
unfortunates must needs eat alone. When there is constant suffering, 
there are certain places in which the pain is felt — at the points of 
emergence from the bony foramina of the different divisions, and 
where certain filaments become superficial. The frontal and supra- 
orbital, the infra-orbital, and the mental, are examples of the first class, 
and tenderness and pain are developed by pressure on the nerves at 
these foramina. These are nearly if not quite constant ; but those are 
less so, felt at the points where the nerves become superficial. The 
pains radiate from the painful points in both directions, but chiefly 
toward the periphery, and from the center, on other nerve-trunks — on 
the pneumogastric, on the occipital, etc. The sensibility of the part, 
innervated by the affected nerve, is altered; there may be merely per- 
verted sensations, tingling, formication, etc., or anaesthesia when the 
case is old, hyperiesthesia when the attacks are recent. Photoj^hobia, 
amblyopia, blepharosj^asm, and spasms of the facial muscles occur dur- 
ing the paroxysms. Various vaso -motor disturbances ensue, such as 
herpetic eruptions (zoster), eczema, falling out of the hair, a glossy 
state of the skin, ophthalmia, in old cases, and in the recent attacks, 
injected conjunctiva, lachrymation, swollen face, thickened skin, inject- 
ed nasal mucous membrane, etc. When paroxysms are brought on by 
eating, and when sleep is prevented, the general health declines, but 
otherwise there may be no constitutional symptoms. Tic-douloureux 
may occur in one or all divisions of the fifth ; more frequently it is 
either confined or is most violent in one of these divisions. When the 
ophthalmic division is affected, pain extends into the forehead and 
temples, the eyelid, and the eye itself. The principal painfal spot is 
at the supra-orbital foramen ; there is considerable hypera3mia of the 
conjunctiva, photophobia, and spasm of the orbiculus palpebrarum. 
When the second division is attacked, the pain is felt in the superior 
maxilla, in the teeth, and the upper lip. The principal tender point is 
at the infra-orbital foramen. When the third or inferior maxillary 
division is attacked, the pain is felt in the lower jaw, and in the teeth, 
and the most certain painful point is the mental foramen. 

Course, Duration, and Termination. — Tic-douloureux may be sev- 
eral years in its development, attacks of pain becoming gradually 
more severe, better defined, and paroxysmal. It is therefore a chronic 



732 



DISEASES OF THE NERVOUS SYSTEM. 



disease. That form dependent on malarial infection occurs more 
abruptly, has distinct periodicity, and terminates promptly, if appro- 
priately treated, or assumes some other form. If caused by an aneu- 
rism, or tumor, or exostosis, the course is slow but usually uniform, and 
the pain and hypersesthesia are excessive ; but after a time anaesthesia 
occurs and the pain declines. In the purely neuralgic form there is 
no regularity in the paroxysms, and a state of the peripheral nerves is 
ultimately reached when paroxysms are induced by the slightest move- 
ment. In the rheumatic subject, changes of temperature and baro- 
metric pressure may determine attacks which can be predicted. The 
simpler forms may terminate in recovery, but those cases due to 
exterior pressure on the trunk of the nerve within the cranium are 
incurable. Severe and protracted cases may terminate in epileptic 
attacks, or induce insanity, or lead to suicide. 

Diagnosis. — To determine the cause of the neuralgia may be very 
difficult, and to separate the cases purely neuralgic from those due to 
some intra-cranial growth may be impossible at the outset. There is 
no difficulty in diagnosticating the seat and character of the neuralgia, 
apart from the lesion producing it. An intra-cranial growth affecting 
the nerve will be accompanied by other sensory and motor disturb- 
ances — by strabismus, double vision, vertigo, incoordination, paraly- 
sis, etc. 

Treatment. — In cases produced by some form of infection, syphi- 
litic, rheumatismal, plumbic, or malarial, treatment must necessarily 
be directed to the underlying cause. In every case in which no ex- 
planation is possible of the origin of the disease, it is good practice to 
prescribe a course of iodide of potassium. For the relief of recent 
cases, beginning suddenly and with violence, full doses of quinine and 
morphine (gr. xv — gr. xx of quinine and gr. ss. of morphine) are to be 
commended. Duquesnel's aconitine in solution, internally, in from 
grain to -gV gi'^in, even -^^^ grain very cautiously, has been successful in 
some cases of -pure neuralgia of the fifth. Fluid extract of gelsemium 
has had a curative effect in some cases, and a palliative effect in others. 
It should be carried to the point of inducing ptosis, dilated pupil, and 
muscular languor. To afford relief, there is no remedy comparable to 
the subcutaneous use of morphine, and this relief may be permanent, 
but is not frequently so, and the danger of inducing a morphine-habit is 
very great in a disease of this kind. The combination of morphine and 
atropine is preferable to morphine alone. Atropine hypodermatically 
has effected a cure in some cases. These remedies, if continued for a 
great while, lose their effect, and the pain which they at first relieved 
seems to be caused by them at last. Injections in the vicinage of the 
diseased nerve have been used with success. Water has been so used, 
and has afforded some relief. Of all the remedies thus far proposed 
none have been so successful as the deep injection of chloroform. Thia 



NEURALGIA. 



733 



method is adapted to those cases of neuralgia in nerves superficially 
placed, as the supra- and infra-orbital nerves, because the chloroform 
must be deposited about the nerve or in its neighborhood. The author 
has published some cases showing the extraordinary relief, lasting 
months, and permanent cures which have thus resulted. The method 
consists in depositing in the neighborhood of the nerve from five to 
ten minims of pure chloroform by means of the hypodermatic syringe. 
The constant galvanic current, by the polar method, always affords 
great relief to the pain, and may in purely neuralgic cases bring about 
a cure. Daily applications of a few minutes should be kept up for a 
long time if improvement continues. Means to promote the nutrition 
of the body are important, for in neuralgia the vital forces are usually 
depressed. If anaemia exists, iron is necessary. Arsenic is one of the 
most powerful of the so-called nerve-tonics, and is particularly service- 
able when indigestion exists. The phosphates and cod-liver oil are 
highly useful in the tic-douloureux which succeeds to lactation, or in 
all conditions of bodily depression. Nerve-stretching in this as in 
other forms of neuralgia is an expedient which should be tried when 
milder means fail, 

OERVICO-OOCIPITAL, CERVICO-BRACHIAL, INTERCOSTAL, AND 
LUMBO-ABDOMINAL NEURALGIA. 

Pathogeny and Symptoms. — The cervico-occipital neuralgia is sit- 
uated in the region innervated by the four upper cervical nerves. 
The pain is felt in the occipital region to the vertex and ear, the neck 
downward to the clavicle, and upward and forward to the cheek, but 
chiefly in the distribution of the occipital nerve. The pain may occur 
on one side or both, but usually on one, is deep, heavy, and tensive, or 
sharp and lancinating, is paroxysmal, severe, and is increased by every 
movement, so that the head is held rigidly in one position. The course 
of the occipital nerve is tender. Hyperaesthesia of the skin and cramps 
in the cervical muscles occur, and attacks of herpes are common. — 
Cervico-hrachial neuralgia arises under the same conditions as the 
other forms. The pain is very severe, of a boring, burning, heavy, 
and tensive character, and is usually very severe at night. The pain 
is accompanied by a sense of numbness, and weakness of the arm and 
hand, and is most severe in the shoulder and arm, but it extends down 
as far as the inferior angle of the scapula, and is often very strong in 
the mamma of the same side. The cervical plexus is very tender, and 
painful points are felt behind the acromion process, at the outer part 
of the insertion of the deltoid, over the median and ulnar, etc. The 
spinal apophyses, corresponding to the origin of the nerves implicated, 
are tender. Besides the pain developed by pressure, the skin of the 
arm at various points is hyperaesthetic, notwithstanding the numbness. 



734 



DISEASES OF THE NERVOUS SYSTEM. 



The arm feels heavy and useless, and power is actually impaired. At 
the outset, the arm is swollen somewhat, hot and rather red, but in an 
advanced case it shrinks from disuse, becomes pale, the skin glossy, 
dry, and harsh. — Intercostal neuralgia is produced by causes besides 
those of the other forms of neuralgia. Aneurisms and tumors of the 
chest cause very violent attacks of pain. Diseases of the vertebra 
and ribs have the same effect. The pain is of two kinds — a feeling of 
soreness with fatigue, and an acute lancinating pain. As in the other 
forms of neuralgia, the pain is paroxysmal, remits and even intermits. 
Pain in the left side, usually referred to the sixth or seventh inter- 
costal space, is very common in women, and is apparently due to ova- 
rian and uterine irritation. Intercostal neuralgia not unfrequently 
takes the form of herpes zoster or shingles. The author has seen eight 
cases in which the herpes seemed to be due to arsenic, and others have 
made the same observation, so that the assumption, that, when zoster 
accompanies intercostal neuralgia, neuritis is the cause of both phe- 
nomena, seems hardly justified. In young persons there is not much 
neuralgia with zoster, and, in the old, the neuralgia precedes and suc- 
ceeds the eruption. In most cases there is a burning pain which comes 
on just as the eruption is about to appear, and also acute lightning- 
pains shooting through the chest. — Lumho- abdominal neuralgia in- 
cludes the ileo-hypogastric nerve, the ileo-inguinal, and the external 
spermatic nerve supplying the hypogastrium, integument of the hip, 
the inner face of the thigh, and the scrotum or labium, but neuralgia 
of these nerves is rather uncommon. 



SCIATICA. 

Definition. — The sciatic plexus is made up of the fourth and fifth 
lumbar and the first two pairs of sacral nerves. The term sciatica is 
applied to a neuralgic affection of the sciatic nerve. Sciatica is, next 
to tic-douloureux, the most important of the neuralgic affections. 

Pathogeny and Symptoms. — Constitutional predisposition and he- 
redity have less to do with sciatica than with any of the other forms of 
neuralgia. The disease occurs much more frequently in men than in 
women. Direct injury to the nerve in certain positions — sitting, espe- 
cially if the form of the seat is such as to direct the weight of the 
body on the nerve ; by prolonged walking ; by constipation, the 
bowel being distended with hardened faeces — is the most influential 
cause. To these must be added exposure to cold and dampness, as, 
for example, prolonged sitting on a damp stone, fatiguing work in the 
standing posture in water, etc. These causes are the more influential 
if the system is predisposed by rheumatism and other cachexise and by 
the neuropathic constitution. It may be stated, in general terms, that 
sciatica is produced by the same causes, constitutional, immediate, and 



SCIATICA. 



735 



remote, that other forms of neuralgia are, but that it is much more 
likely to be developed by local and mechanical than by systemic and 
constitutional causes. The only pathological alterations proper to 
sciatica are those of neuritis. As a result chiefly of disuse, the af- 
fected limb wastes more or less in severe cases. The disease develops 
slowly. In most of the cases observed by the author, an attack of 
lumbago preceded the sciatica, and the pain gradually became fixed 
in the sciatic. In several cases (four) the pain began in the heel. In 
other cases the first symptom noted was a feeling of pain and soreness 
in the hip. A feeling of stiffness, numbness, formication, heaviness 
of the limb, and other abnormal sensations have been noted. In what 
way soever the disease begins, soon severe pains occur in distinct 
paroxysms. The pains are lancinating, tearing, grinding, and they 
shoot with lightning-rapidity along the direction of the principal 
nerves. Kow they are felt with greatest intensity in the hip behind 
the joint, again in the calf of the leg, now in the ankle, again in the heel, 
or the pain flies from one to another of these parts, or shoots through 
them all at the same time. The paroxysms last a variable period from 
an hour or two to twenty-four or more hours, sometimes for several 
days, there being brief remissions only. The pain is almost always 
worse at night. In the interval between the paroxysms the limb is 
heavy, movements excite pain, and there is a tensive, throbbing sen- 
sation which threatens severer suffering. Exercise usually increases 
the pain, and unguarded movements may bring on a paroxysm. The 
trank of the nerve behind the trochanter is sensitive to pressure, also 
in the popliteal space ; there are tender points at the head of the 
fibula, behind the inner malleolus and also behind the outer malleolus, 
and there is tenderness of the lumbar apophyses. The pain often 
radiates into the lumbar nerves, into the sciatic of the opposite side, 
and into the scrotum and testes. Hypersesthesia and cramps occur at 
first, and in old cases diminished sensibility, lowered temperature, and 
wasting are observed. The appetite is impaired, there is little sleep 
in bad cases, and hence the bodily forces decline. At first the limb is 
used awkwardly, the patient limps, then crutches are resorted to, and 
finally the bed is the only resource. The pitiable state to which a 
man can be reduced by a severe sciatica is told by a sufferer, himself 
a physician. Dr. Lawson:* "The pain persisted for more than six 
months ; it first reduced me to the employment of crutches, and then 
absolutely prevented locomotion ; the limb became permanently flexed 
and terribly wasted ; nearly every remedy in the Pharmacopoeia, and 
many out of it, were tried in vain ; . . . for six months I had hardly 
known what sleep was, notwithstanding the administration of opiates 
three or four times a day. Appetite was utterly lost ; physical power 

* " Sciatica, Lumbago, and Brachialgia, etc.," by Henry Lawson, M. D., London, 
18Y2, p. 7. ^ 



Y36 



DISEASES OF THE NERYOUS SYSTEM. 



was prostrate ; mind, through long suffering, was enfeebled to that 
degree that I look back upon that period of my existence with aston- 
ishment and horror." Of course, not all cases are so severe as this of 
Dr. Lawson, but in every mild case suffering is experienced, the sleep 
is broken more or less, but the general health does not suffer any con- 
siderable deterioration. 

Course, Duration, and Termination. — After the first acute symp- 
toms, when the case begins with lumbago and a feverish state, the course 
is chronic and like the usual pattern. When the symptoms develop 
slowly, the disease reaches its maximum in a few days, or a week or 
two. If the treatment be appropriate, a termination in health may 
take place in two or three weeks. The cases often continue months 
and years, in varying condition, now improving, then getting worse. 
In the author's experience, there are two climatic states which exercise 
an unfavorable influence — variable cold and damp weather and con- 
tinued high temperature ; while uniform dry cold has a favorable effect. 
Quite irrespective of climatic changes, sciatica has a strong tendency 
to relapses. Some cases gradually subside without any properly di- 
rected treatment, and get well in a year or two. Many do not recover 
entirely, although there may not occur any acute paroxysms ; the 
limb continues weak and a halting gait persists, because of imper- 
fect combination of the muscles. Cases occurring in old subjects, 
whose symptoms present the evidences of senile degeneration, may 
continue during life. 

Diagnosis. — Ordinarily a case of sciatica does not offer any difficul- 
ties for careful consideration. It may be confounded with muscular 
rheumatism, with the first stage of hip- joint disease, and with hysteri- 
cal joint. Muscular rheumatism differs from sciatica in the lesser se- 
verity of the pain, in the absence of distinct paroxysms, and in the 
diffusion of the symptoms, the distress in the one being distributed 
over the principal muscles, in the other confined to the nerve-trunks 
and to certain painful points. In incipient joint-disease there may be 
much sciatica, so that the distinction must rest on the changes in the 
shape of the hip, in the gluteal fold, and in the position of the foot, 
which, with the history, ought to indicate the existence of hip-joint 
disease. The hysterical joint is differentiated by the absence of any 
evidence of suffering, by great tenderness in the skin, and yet, when 
the attention is withdrawn, by entire lack of tenderness in the nerve- 
trunk or in tender points, and by the evidences of hysteria present. 

Treatment. — Existing causes should be removed. If the attack 
depends on impaction at the flexure or csecum, active purgatives should 
be prescribed. A particular chair or habit of sitting may be respon- 
sible, and should be changed. If the attack begin by lumbago, warm 
baths, Russian or Turkish, may soon effect a cure. Dr. Lawson, 
whose shocking experience has been referred to, after six months of 



SCIATICA. 



737 



unavailing treatment, was at once relieved and speedily cured by the 
hypodermatic injection of morphine. His little work, written to ad- 
vocate this treatment, contaias numerous cases illustrating its utility. 
Morphine (gr. -J- to gr. J) and atropine (gr. to gr. to gr. -^V) are 
more effective in combination than morphine alone. The injection is 
somewhat more effective when inserted in the neighborhood of the 
affected nerve. There can be no doubt that this treatment is sufficient 
in itself in many cases, but it can be aided by other measures, local and 
systemic. The author has witnessed remarkable cures of chronic cases 
by the deep injection of chloroform. This practice consists in the 
injection of five to ten minims of chloroform, thrown deeply in the 
neighborhood of the nerve near to the point of its emergence from the 
pelvis. The injection should also be practiced at those points where 
the pain has been severe. But few injections are necessary. Ether 
may be used also, but it is more irritating and less effective. The 
author has cured many cases by stabile applications of galvanism 
alone. A large sponge electrode should be applied over the nerve 
near the point of exit from the pelvis, and the other electrode below. 
Strong currents are more effective and, indeed, indispensable for cura- 
tive results. Successive portions of the nerve should be included in 
the circuit, by applying the anode over the painful points and the 
cathode below, according to the method of Remak.* Eulenberg,f 
Erb,J; and Althaus, are fully agreed as to the success of the galvanic 
current in sciatica. Hammond has revived the method of Magendie, 
and now cures sciatica by inserting an acupuncture needle, insulated 
to near its end, and passing through it a current from a few cells. 
Firing is often very successful. The hammer, dipped in boiling water, 
is applied to produce redness and slight vesication, or considerable 
burning, according to the duration of the case. Great relief and even 
curative effects have followed the application of blisters, the raw sur- 
face dressed with powdered morphine. Flying-blisters are beneficial. 
The warm pack and the rubbing pack are of great service in obstinate 
cases. The pack may be worn all night. In the chronic cases of sup- 
posed rheumatic origin, iodide of potassium guaiacum and turpentine 
are said to be useful, but the author has not seen any good results 
from them. The other forms of neuralgia referred to above require 
the same treatment. Any local injury, constitutional condition, or 
cachexise, must be removed. The most successful remedies are the 
hypodermatic injection of morphine and the constant current, the cura- 
tive influence of which few cases resist. 

* " Galvanotherapie, traduit de I'Allemand par le Dr. Morpain," Paris, 1860, p. 374 
f " Lehrbuch der functionellen Nervenkrankheiten," op. cit, p, 168. 
X Ziemssen's " Cyclopaedia," vol. xi. 



49 



738 



DISEASES OF THE NERVOUS SYSTEM. 



SPASM OF THE FACIAL MUSCLES SUPPLIED BY THE SEV^ 
ENTH NERVE— CONVULSIVE TIC— HISTRIONIC SPASM. 

Definition. — The seventli nerve is distributed to the muscles of ex- 
pression. The attacks of spasm may occur in all or a part of these 
muscles. Convulsive tic or mimetic S2msm is the term applied to the 
former ; blepharospasm is the name given to spasm of the eyelids. 

Pathogeny and Symptoms. — Various causes are assigned for the 
production of mimetic or histrionic spasm. The constant activity and 
variety of movement in expressing the various emotions render these 
muscles rather apt to take on abnormal movements. This is seen in 
tricks of expression imitated from others, and also inherited, but the di- 
rect transmission of histrionic spasm is not common. Men are more apt 
to suffer from this malady than women. It may occur as a secondary 
symptom in such convulsive disorders as chorea, epilepsy, etc. It may 
be developed from purely psychical states, as anger or fear, but then 
a predisposition must exist. It is more apt to arise from direct or 
reflex irritation of the facial nerve. Tumors, caries of the bones, dis- 
eased teeth, periostitis, and remote irritation, as intestinal worms, have 
set up the spasms. The disease begins in a small group of muscles, 
and then extends to all the muscles, on one side usually, although both 
sides may be affected. It consists in a succession of clonic spasms, 
producing extraordinary grimaces and contortions. If one side, it is 
all the more striking by comparison with the unmoved state of the un- 
affected side. The spasms occur in paroxysms, lasting a few seconds 
or a few minutes. They begin in one group of muscles by a few 
twitches, and then clonic spasms follow in all the others. It is a rule, 
however, for the attack to be more decided in some one muscular group, 
as in the orbicularis palpebrarum and corrugator supercilii, and leva- 
tor labii superioris et alseque nasi and levator anguli oris. The num- 
ber of the attacks varies greatly, usually several occurring every hour, 
and they may persist during the night, but this is not usual. They 
are excited by attention to them, by talking, by emotion, and by 
increased irritation of the nerve-trunk. They do not interfere with 
the normal use of the, muscles at other times. Extension of the spasm 
may take place to the muscles of the tongue and to those of mastica- 
tion, and in severe paroxysms the muscles of the neck and shoulders 
may participate. The electro-contractility of the muscles remains un- 
affected. Blepharospasm is the form of the disease attacking the eye- 
lid. This consists of paroxysmal attacks of sudden closure of the lids, 
with spasms of the annexed muscles, producing extraordinary grimaces 
of the affected eye. The attacks may occur suddenly without any ap- 
parent cause, or be induced by straining or irritation of the eyes, by 
opening or closing the lids. The conjunctiva is injected, there is a 
profuse secretion of tears, and an extreme degree of photophobia may 



TORTICOLLIS. 



739 



exist. These changes may be the result of blepharospasm, but, in a 
great majority of cases, diseases of the eye, as scrofulous conjunctivitis, 
corneitis, wounds, by irritating the sensory fibers of the fifth, excite 
the spasms by a reflex mechanism. In this disease certain so-called 
pressure-points exist, pressure on which will suddenly arrest the par- 
oxysms. These have no fixed position, as the painful points in neu- 
ralgia, and can not be indicated beforehand in any case, but must be 
searched for. They are sometimes found at the supra-orbital foramen, 
and on various branches of the fifth nerve in the face, the gums, the 
malar bone, and the mastoid process, and if not detected in these situ- 
ations may be discovered in the brachial plexus, the spinous processes, 
or the sympathetic. Pressure on these points exerts an inhibitory influ- 
ence on the spasms, which may be suspended for some time. On the 
other hand, the influence of the pressure-points may continue only 
during the pressure (Erb). 

Treatment. — The removal of any cause of irritation, intrinsic or 
extrinsic, is necessary. As blepharospasm is so often due to strumous 
diseases of the eye, these must be removed before any influence can 
be exerted on the spasm. Remarkable results have been obtained 
from the free use of succus conii in this malady ; in recent cases, the 
subcutaneous use of morphine, and morphine and atropine. The hypo- 
dermatic injection of Fowler's solution has succeeded remarkably in 
some cases of tic. From two to five drops can be injected daily about 
the pes anserinus. The constant current (stabile) applied to the pres- 
sure-points, the positive pole on the point, the negative held on some 
part of the periphery, has been successful in some cases. The sympa- 
thetic, the mastoid process, the vertebrae, etc., are also possible pressure- 
points to which the current should be applied. Remarkable results 
have followed the section of the supra-orbital nerve in a few cases. 

SPASM OP THE MUSCLES SUPPLIED BY THE SPINAL AO- 
OE SSORY— TORTICOLLIS. 

Pathogeny and Sjrmptoms.— The trapezius and the sterno-cleido- 
mastoid are the muscles affected either separately or together, and the 
attack may be unilateral or bilateral. In unilateral spasm of the 
sterno-cleido-mastoid, the head is rotated a little, the chin elevated 
and turned to the other side, and the occiput is brought forward and 
downward in the direction of the clavicle. If the trapezius is alone 
affected, the head is drawn down and backward, and the shoulder up- 
ward and inward toward the spine. When both muscles are affected, 
there is a combination of the movements, and they may alternate. In 
bilateral spasms of the spinal accessory, the head is drawn from one 
side to the other, and the chin correspondingly turned in the opposite 
direction. If the sterno-mastoids are alone affected, there occur sym- 



740 



DISEASES OF THE NERYOUS SYSTEM. 



metrical nodding movements. The attacks of spasm are paroxysmal, 
and are of variable duration, lasting from a few minutes to a number 
of hours. They may be very severe, tossing the head from side to 
side in a terrible manner, and may be almost continuous, involving 
also the muscles of the face, of mastication, and of the shoulder. 
Sleep usually arrests the movements, and is quiet and undisturbed, 
although it may be delayed, and sometimes entirely prevented. The 
paroxysms are excited by any kind of irritation, as of talking, mental 
excitement, anger, and are increased by the attention given to the 
spasms by others. As a necessary result, the wild, disorderly, and 
very strong movements exhaust the muscles. In the course of the 
paroxysms, speech and mastication are prevented. The unpleasant 
condition of these patients and the nervous disorder probably associ- 
ated with it slowly bring about a mental change. These patients are 
depressed and gloomy, sometimes suicidal, and, in the further progress 
of the case, epilepsy, paralysis, or insanity may be a result. 

Treatment. — There is little to encourage therapeutic effort, and 
partly because the origin remains obscure. Those cases brought on 
by exposure of the neck to draughts of cold and damp air are the 
most remediable. If there be a source of reflex irritation which can 
be removed, as worms, indigestion, or uterine disease, the muscular 
disorder may be readily cured if treated in time. When there are 
intra-cranial lesions, or if the case be chronic, and occurring in the 
neuropathic constitution, the treatment is in vain. The best results 
are obtained from the constant galvanic currents, stabile applications, 
and by applications to the sympathetic and to the spine. Next in 
efficiency is the hypodermatic injection of morphine, if possible, into 
the muscles affected. The injections of arsenic should be tried in 
doubtful cases. The warm pack should be steadily worn at night, 
and douches to the cervical spine applied warm or cold, according 
to the results. The actual cautery has been used with success in a 
few cases. In that form of torticollis in which the muscles assume 
a condition of tonic spasm, they are fixed in a permanent position 
by contraction. If the sterno-cleido-mastoid is affected, it stands out 
prominently and is enlarged and rigid, and the head assumes a charac- 
teristic attitude, the chin turned away, and the occiput brought down 
and forward toward the clavicle. When the trapezius is alone affected, 
the head and shoulder are approximated, and the anterior border of the 
muscle forms a prominent, rigid swelling. The affected muscles have 
a sore, tired feeling, and are tender to the touch when the affection is 
recent. The antagonistic muscles after a time undergo atrophy, and 
hence the overacting muscles are aided in maintaining the fixed posi- 
tion of the head. In young spines a permanent curvature of the cer- 
vical part takes place, and the features accommoddle themselves to the 
changed position of the head in a most remarkable way. The bones 



HICCOUGH. 



Ul 



of the face undergo a slow transformation to permit the features to 
assume the new relations. In this disease it is highly important to 
undertake the treatment before the deformity becomes permanent. 
Electricity is entitled to the first place as a remedy. There are two 
methods of application to be employed. Stabile applications are to be 
made to the muscles in a state of spasm, and faradic currents to the 
antagonistic muscles. "Warm packs, massage, and gymnastic training 
are useful. Surgical treatment is necessary in chronic cases. 

SPASM OF THE DIAPHRAGM— SINGULTUS— HICCOUGH. 

Pathogeny and Symptoms. — This malady consists in a recurring 
spasm of the diaphragm ; there is first a full expiration, then a sudden 
^inspiration, accompanied by a high tension-sound, caused by a spas- 
modic closure of the glottis. It is often present without having any 
significance. It is a symptom of certain kinds of indigestion, and is 
present only during the stage of digestion. Distention of the stomach 
may cause it. Hepatic diseases — peritonitis, chronic ileocolitis — are 
maladies during the course of which hiccough may come on, especially 
in the collapse which ushers in death. It is a symptom of irritation 
of the respiratory center, and of various diseases of the central nervous 
system, and is one of the manifold forms in which hysteria manifests 
itself. The worst case ever seen by the author occurred after a severe 
attack of hepatic colic. When the paroxysms are protracted and the 
hiccough is frequent, very considerable suffering is the result. The 
hiccough may occur as often as one hundred to the minute, and the 
paroxysms may continue for some hours or days, returning from time 
to time during several years. The attacks may have a certain rhythm, 
three, six, or other numbers occurring in succession, then an intermis- 
sion. When a severe paroxysm comes on, severe pain is felt in the 
epigastrium, the respiration is disturbed, eating is difiicult, and sleep 
may be prevented. 

Treatment. — A strong mental impression or a draught of very cold 
or very hot liquid will sometimes succeed in arresting hiccough. Elec- 
tricity is usually very successful. In the severe case just mentioned 
the author arrested the spasm instantly, after all kinds of remedies, in- 
cluding galvanization of the phrenic, had been tried in vain, by send- 
ing a strong faradic current through the diaphragm just as the spasm 
was about to occur. The inhalation of ether, of nitrite of amyl, and 
the injection of pilocarpine, have all promptly succeeded. 

PARALYSES OF THE OCULAR MUSCLES. 

Pathogeny and Symptoms. — Paralysis of the muscles of the eye is 
a symptom rather than a disease. Rarely does a case happen in which 



742 



DISEASES OF THE NERVOUS SYSTEM. 



the paralysis is due to rheumatic inflammation. More frequently 
penetrating wounds, contusions, and fractures, are causes. The sec- 
ondary paralyses are more numerous than the primary. Diseases of 
the brain, such as cerebral haemorrhage, tumors so situated as to com- 
press the nerve-trunks, aifections of the spinal cord, as posterior spinal 
sclerosis, and the paralysis following diphtheria, are the most influen- 
tial causes. When the muscles are weak, the movements of the ocular 
globe are affected, a fact which may be made apparent by comparing 
the sound with the impaired eye ; the limit of rotation will be seen to 
be less, and the obvious result is strabismus. Before this is apparent 
by ordinary inspection, the patient complains of diplopia (double 
vision). Or there is confused double vision, the patient being affected 
only in certain parts of the visual field. The secondary deviation of 
the sound eye is a very characteristic sign. " The field of vision is 
displaced in the direction of the action of the paralyzed muscle," which 
leads to erroneous perception of the position of objects. The disturb- 
ances of vision caused in this way induce giddiness and more or less 
pain. Covering the eye prevents, of course, the formation of a double 
image, and thus affords some relief. When the motor oculi is para- 
lyzed, there is ptosis (dropping of the eyelid), and the movements of 
the eye downward, inward, and upward, are lost. The pupil is dilated 
and motionless because of the unopposed action of the sympathetic, and 
the power of accommodation to near and distant objects is very much 
lessened. As the external rectus and superior oblique continue in 
action, the eye becomes fixed in the direction downward and outward. 
The eye is usually prominent because of the paralysis of the straight 
muscles, allowing the globe to glide forward. There is double vision, 
and, as the field of vision is falsely projected in every direction, there 
is great disturbance of visual perceptions, and consequently giddi- 
ness, so that the eye is ordinarily kept closed. In paralysis of the ab- 
ducens, the external rectus muscle is unable to move the eye outward, 
and there is consequently convergent strabismus. 

Course, Duration, and Termination.— There are very great varia- 
tions in the course of these affections, as they are dependent on various 
causes. The rheumatic affections may be regarded as curable with 
comparative facility, but those examples due to intra-cranial lesions, 
unless syphilitic, pursue the course of the original disease, and are 
incurable. The accompanying symptoms are of great importance 
in coming to a conclusion as to the seat and character of the local 
disease. 

Treatment. — If syphilitic, rheumatismal, or plumbic lesions be the 
cause, the treatment appropriate to these diatheses should be carried 
out. In the absence of any specific cause, a course of the iodide of 
potassium should always be undertaken. The most important remedy, 
and one from which most striking results are obtained, is electricity. 



FACIAL PARALYSIS. 



743 



Labile applications of galvanism are the most effective — the anode 
placed on the mastoid, and the cathode passed over the eyelids. The 
current must be strong enough merely to cause movements of the facial 
muscles, and the length of the sitting should be about three minutes. 
The sympathetic may also be galvanized in the usual way. The fara- 
dic current, which is greatly more painful, may be used instead in some 
cases — one pole on the temple, and the other, covered with soft leather, 
to the conjunctiva at the situation of the paralyzed muscle, if possible. 

PARALYSIS OF THE FACIAL NERVE— FACIAL PARALYSIS. 

Causes. — Exposure to a current of cold air, directed against the 
main divisions of the nerve in front of the ear (pes anserinus), is the 
most usual cause, and of the simplest variety of the disease. Such 
exposure acts by exciting some inflammation of the neurilemma ; in 
the Fallopian canal serous and occasionally plastic exudation occurs 
and compresses the nerve. Injuries to the nerve in front of the ear 
are very common, but the most usual cause, next to cold — the so- 
called rheumatic inflammation — is disease of the middle ear. Syphi- 
litic deposits, gummata, etc., may invade the nerve before its entrance 
into the canal, and also various diseases of the basal ganglia, tumors, 
exostoses, etc. Again, facial paralysis occurs with hemiplegia, or it 
may be crossed in disease of the pons. 

Symptoms. — No disease is more distinctive than facial paralysis. 
The affected side is perfectly blank, motionless, without wrinkles, the 
corner of the mouth depressed, the eye wide open, and the tip of the 
nose and the whole side drawn over to the healthy side, which is more 
strongly marked by furrows and wrinkles than before. This condition 
of the muscles may occur suddenly : the patient, on looking in the mir- 
ror in the morning, is astonished and alarmed at the change ; or, feel- 
ing an odd sensation in the lips and tongue, he attempts to expectorate, 
and finds he can not use his lips properly. There may be premonitory 
symptoms for some hours, even a day or two before the attack, con- 
sisting of numbness and tingling of the lips, a strange taste, acid or 
metallic, pains in the face or ear-ache, noises in the ear, or there may 
be present an otorrhoea. Again — and this is especially true of disease 
of the middle ear — the paralysis may develop slowly, one group of 
muscles, then others, becoming paralyzed, and, when complete, all of 
the muscles innervated by the seventh nerve are affected. When this 
occurs, no movements can be effected by these muscles. The eye 
remains open ; the conjunctiva inflames in consequence of the particles 
of dirt which alight and adhere ; there is a profuse flow of tears ; in 
attempts to close the eyes, the upper lid falls and the globe rotates 
upward and inward, but the lids do not approximate, and hence the 
eye remains open, and in time the lower lid becomes somewhat everted ; 



744 



DISEASES OF THE NERVOUS SYSTEM. 



the forehead can not be corrugated. The corner of the mouth can not 
be elevated, the lips can not be pursed up in the attempts to whistle, 
and in smiling the affected side remains motionless, while the sound is 
acting strongly. The saliva escapes from the mouth, and the labials 
can not be pronounced, whence the speech is rather mumbling and in- 
distinct. Mastication is difficult and the alimentary bolus accumulates 
in the cheek of the paralyzed side. Not unfrequently the sense of 
taste on one side of the tongue is abolished, and the secretion of saliva 
lessens. When this is the case, the chorda tympani, which Schiff has 
shown is the nerve of taste to the anterior half of the tongue, is af- 
fected, and it therefore follows that the seventh is damaged at the 
point of origin of this nerve. The uvula is often affected also, and 
hangs paralyzed, deviating toward either side. When this organ is 
affected, the speech is nasal, swallowing is difficult, and liquids come 
through the nose. This paralysis of the uvula is necessarily due to 
implication of the superficial petrosal nerve. The ear is usually unaf- 
fected, although noises are heard. The sensibility of the paralyzed 
side is normal. The reflex movements are entirely abolished when 
the disease occupies any part of the trunk of the seventh from its ori- 
gin outward. In case of hemiplegia the reflex excitability is pre- 
served. In the mildest cases the electro-sensibility and contractility 
are perfectly normal. In the more severe cases the muscles may not 
respond to a faradic current, yet do respond to a slowly interrupted 
galvanic current ; but the nerves themselves lose their excitability to 
both currents during the period of regeneration. The muscles may 
ultimately lose their galvanic excitability when they have undergone 
advanced changes. When this is the case, the prognosis is unfavorable. 

Course, Duration, and Termination. — When the external branches 
of the seventh only are affected, and by such a simple cause as ex- 
posure to a current of cold air, the duration will be short, and recov- 
ery effected in two or three weeks. The more severe cases may 
require twice the time of the former. In those cases characterized by 
loss of faradic and retention of galvanic excitability of the muscles, 
the duration will be several months, even a year may elapse before 
restoration. In these cases, after a time, the muscles become rigid and 
retract somewhat, and they may be affected by spasmodic contractions 
resembling tic. In traumatic paralysis, the amount of recovery de- 
pends on the extent of injury to the nerve. Usually restoration in the 
most favorable cases is incomplete. The same observations may be 
made of paralysis from pressure of the nerve, the degree and curabil- 
ity of injury determining the result. 

Diagnosis. — The diagnosis is reached by mere inspection, but to as- 
certain the seat of the injury to the nerve is more difficult. Whether" 
peripheral or central is arrived at by attention to the following 
points : in peripheral paralysis, the eye is wide open even in sleep, 
and reflex movements of the lids arc abolished, which is not the case 



HEMICRANIA. 



745 



in cerebral paralysis ; the abolition of faradic and the retention of 
galvanic excitability and the degeneration of the muscles which are 
not present in the cerebral form ; in the latter are observed various 
cerebral symptoms. The position of the disease in the trunk of the 
nerve may be determined as follows : paralysis of the muscles of the 
face, without involving taste, indicates with other symptoms disease of 
the nerve anterior to the origin of the chorda tympani ; paralysis of 
the muscles, no reaction to faradic but response to galvanic current, 
paralysis of uvula, indicate lesion of the nerve at the origin of the large 
superficial petrosal nerve which goes to the spheno-palatine ganglion. 
When there is alternating paralysis, the lesion is most probably in the 
pons. If partial paralysis exist, the velum palati being affected at the 
same time, and if the reflex and electrical excitability are ]3reserved, 
the lesion is in the opposite hemisphere of the brain or its crus. 

Treatment. — The cause of pressure on the nerve within the cavity of 
the cranium, or disease of the ear, should be removed if practicable. In 
all doubtful cases a course of iodide of potassium should be prescribed. 
If the attack is of the rheumatic variety — so called — blisters to the mas- 
toid and the internal use of pilocarpine are the most effective measures. 
The application of electricity, the galvanic current preferably, should 
be begun at once, and continued faithfully until a cure is effected or dis- 
covered to be unattainable. The application should be made by one pole 
— the anode — on the mastoid, and the cathode passed over the terminal 
filaments of the nerve as distributed to the muscles. 



YASO-MOTOR K^Jy TROPHIC ISTEUROSES. 



HEMICRANIA— MIGRAINE. 

Definition. — By the term hemicrania is meant a unilateral pain in 
the head, irregularl}^ periodical, and accompanied by nausea and some- 
times vomiting, and excited by certain reflex disturbances. By the 
French writers it is termed migraine, which has been naturalized to a 
large extent in our country, and it is known in common language as 
sick-headache. 

Causes. — Regarded by Romberg as an hyperesthesia of the brain, 
the localization of the disturbance in the vaso-motor system was first 
distinctly afiirmed by Du Bois-Reymond, who maintained that the cause 
of the affection is a contraction of the arterioles on the affected side 
of the head — a fact determined by observation on himself. An oppo 
site view of the state of the sympathetic was taken subsequently by 
MoUendorff, who maintained that the vessels are relaxed. As is often 
the case, the truth probably lies between these extremes, as Eulenberg 



746 



DISEASES OF THE NERVOUS SYSTEM. 



maintains. Females are more liable than males, and in early life the 
disease first manifests itself. It is distinctly inheritable, or at least the 
neuropathic constitution. 

Symptoms. — The disease is irregularly paroxysmal, and in the inter- 
val between the attacks there is no pain or other disturbance. The 
paroxysms may or may not be preceded by prodromal symptoms, such 
as weariness, hebetude of mind, etc., but the onset of the attack is 
usually announced by chilliness, nausea, yawning, and general muscu- 
lar soreness. The pain comes on most frequently on the left side, and 
is felt in greatest intensity in the supra-orbital ridge and in the eye, 
but it may be felt nearly equally over the whole side, and even extend 
over beyond the median line ; usually there is a region of greatest 
severity of pain. Tenderness is felt when the cervical ganglia — upper 
and middle — are pressed on, and tenderness is also experienced when 
the spinous processes of the last cervical and first dorsal vertebrae are 
subject to pressure. The sense of touch is more acute than normal 
over the whole area of the hemicrania. In many subjects nausea and 
vomiting precede the attack of hemicrania ; in others the pain con- 
tinues for some time before nausea is experienced, and vomiting often 
ends the attack. Light is hurtful to the eyes, and noises to the ears. 
Rings of light and muscse volitantes float before the eyes, and there 
are noises in the ears. The circulation, temperature, and secretions of 
the affected part are altered. There are, as Eulenberg insists, and as 
the author has repeatedly observed, two kinds of disturbance in the 
circulation : contraction of the vessels, and antemia of the affected 
part, as shown in pallor of the face, shrunken eye and dilated pupil ; 
dilatation of the vessels, flushed and red face, the conjunctivie injected, 
and the pupil contracted. The two forms may coincide, but this is 
rare, and there may be cases in which no disturbance exists in the 
sympathetic ganglia. 

Course, Duration, and Prognosis.— The paroxysms may last for a 
few hours or a day or two. They may occur every few days, every 
week, or every month, or at longer intervals. Women are especially 
liable to attacks about the menstrual period. In many they are in- 
duced by errors of diet. As the pneumogastric nucleus lies alongside 
of the nucleus of the fifth, it is easy to understand the transference of 
sensations. Usually the susceptibility to attacks declines with the ad- 
vance in life and disappears after fifty. The author has frequently 
observed that the disappearance of hemicrania has been coincident 
with the occurrence of cerebral haemorrhage. Otherwise, the disease 
must be regarded as entirely free from danger to life, while its chief 
importance lies in the fact that few cases are permanently cured. 

Treatment. — The most important point is a careful regulation of 
the diet in that large proportion of cases originating in stomachal 
disorder. An easily digested aliment of the nitrogenous kind, with 



A^^GINA PECTORIS. 



747 



decided diminution of the farinaceous and saccharine elements, is the 
kind of diet required. In these cases the best results are obtained 
from the use of arsenic — two drops of Fowler's solution before each 
meal, kept up for months. In the other group of cases, nervous in 
origin, the best remedies are cuca, guarana, caffein, and bromide of 
potassium. The last mentioned is adapted to those cases dependent 
on contraction of the arterioles, and is very effective if administered 
just before the onset of the paroxysm, in a sufficient dose ( 3 ss. — 3 j)? 
and repeated several times. The other remedies mentioned are better 
fitted to give tone to the sympathetic ganglia in the interval between 
the paroxysms. "When there is anaemia, a chalybeate course is highly 
serviceable. AYhen the moral surroundings are such as to cause at- 
tacks, change of scene is highly necessary. If the disposition to the 
malady is inherited, the prophylaxis is very important and should in- 
clude diet, exercise, clothing, and the avoidance of all those conditions 
which tend to develop an abnormal excitability of the nervous system. 
The best results have been obtained from galvanization of the superior 
ganglia of the sympathetic ; the positive pole over the ganglion and 
the negative on the epigastrium in the tetanic form ; and the poles 
reversed in the paralytic form. Frommhold * has obtained the best 
results from the faradic current. 

ANGINA PECTORIS. 

Definition. — A neurosis of the heart, in which there occur parox- 
ysms, characterized by pain in the prsecordial region, extending usu- 
ally into the left shoulder and down the left arm, and accompanied by 
a feeling of constriction of the thorax, and a strong sense of impend- 
ino^ dissolution. It is sometimes called neuralo^ia of the heart. 

Causes. — A predisposition to this affection seems to be inherited. 
It is often associated with chronic cardiac changes, as arteritis of the 
coronary artery, calcification of valves, etc. It is, as Trousseau first 
pointed out, sometimes a masked epilepsy, and again angina pectoris 
may alternate with epileptic attacks. It may occur in hysteria, and 
may precede an outbreak of mania. Males are greatly more liable to 
it than females, and, although it is more frequent in advanced life, 
it may occur at any age. Excessive smoking by young and nervous 
subjects may cause it at a comparatively early age. 

Pathological Anatomy. — Various changes in the heart are found, 
but these are accidental. The pathological changes which stand in a 
causative reht'on to the attacks are those of the cardiac plexus of the 
phrenic and of the pneumogastric nerves. Pressure of enlarged lym- 
phatics, inflammation of parts of the cardiac plexus, with changes in 
the coronary artery, seem to be the most constant (Eulenberg). 

* "Die Migraine und ihre Heilung durch Electricitat," Pesth, IS^'.S, p. 115. 



748 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms. — Angina pectoris is a paroxysmal affection, tlie attacks 
occurring irregularly, and in the interval there are no symptoms. The 
attacks are eminently characteristic. The patient is suddenly seized, 
it may be in the night, during exercise or while resting, with an in- 
tense pain in the prjecordial region, accompanied by a sense of con- 
striction and suffocation. He at once assumes a fixed position as if 
the least movement would cost him his life ; his face becomes deadly 
pale, and a cold sweat bedews the skin. The pain shoots across the 
chest, upward under the sternum and toward the left shoulder, and 
down the left arm. The sudden pain and terror may cause syncope, 
but usually the pain ceases in a few seconds or minutes, and the pa- 
tient takes a deep breath with a sigh of relief. The respiration may 
continue undisturbed, may be very much oppressed, or it may be 
arrested, simply from a fear that the least movement may end life. 
The pulse is small, the action of the heart weak or arrested, and the 
arterial tension very high. A decided contraction of the superficial 
arterioles causes the skin to assume a pallid appearance, and a sudden 
chilliness with chattering of the teeth occurs. When the attack is 
over, the circulation becomes active, the skin warm, eructation of gas, 
sometimes vomiting, occurs, and a quantity of pale, watery urine is 
passed. 

Course, Duration, and Termination. — The course of the disease is 
chronic. The paroxysms have a variable duration — usually lasting a 
few seconds only, but they may continue, with remissions in the sever- 
ity of the symptoms, for hours, even days. The return of the attacks 
is irregular and uncertain ; they may appear after an intermission of 
days, or weeks, or months. It is usually several months after the 
occurrence of the first seizure until the next appears. The nocturnal 
attacks are spontaneous in origin, but those occurring during the day 
are caused by some strong emotion — a fit of anger, chagrin or disap- 
pointment — by some active exercise, or by indigestion. The disease 
may occur irregularly during five to seven years. The importance of 
angina is largely affected by the cardiac lesions w^hich usually accom- 
pany it, and the fatal termination so often observed after two or three 
paroxysms, rarely in the first, is due to these associated cardiac lesions. 
Whether symptomatic or essential, angina pectoris is a fatal malady, 
but the latter form is more amenable to treatment, and offers a longer 
duration than the former. 

Treatment. — All causes of disturbance of the cardiac action, as 
tobacco-smoking, etc., must be removed. Those attacks accompanied 
by vascular spasm — and this seems to be the case during the paroxysm 
in all cases — are most promptly relieved by the nitrite of amyl, origi- 
nally proposed by Brunton. Patients should be provided with the 
perls containing three minims, to be broken in the handkerchief, and 
the vapor inhaled on the instant. This expedient has given relief in a 



EXOPHTHALMIC GOITRE. 



749 



large number of cases. The solution of nitro-glycerine has been used 
most successfully in the interval of the seizures to prevent them. Full 
doses of arsenic (ten minims of Fowler's solution) three times a day, 
after meals, have a good effect. The hypophosphites and cod-liver 
oil, continued steadily for months, have done good in debilitated sub- 
jects. Where a malarial influence may be presumed to exist, quinine 
is the proper remedy. When epilepsy is masked under attacks of 
angina, bromide of potassium affords great relief. Remarkably good 
results have been obtained from galvanism, stabile currents being used 
— the positive pole at the pra^cordia, and the negative over the seventh 
cervical vertebra. 

EXOPHTHALMIC GOITRE (GRAVES'S DISEASE). 

Definition. — Exophthalmic goitre is a disease characterized by a 
quaternary of symptoms — exophthalmus, enlarged thyroid, dilatation 
of the arteries, and palpitation of the heart. It has received a variety 
of designations. In Germany it is known as Basedow^ s disease ; in 
England, Graves^ s disease, from the names of supposed discoverers. 

Causes. — Although a variety of causes have been alleged, few are 
worthy of serious consideration. Heredity, ansemia, and chlorosis, 
moral emotions, have been considered causative, but of these only the 
last appears to have exerted any real influence. In the cases seen by 
the author, fright, chagrin, reverses of fortune, etc., were the causes, 
but it is probable that the effect produced was really due to some pe- 
culiar condition of the nervous system. This disease is more common 
in women than in men — in the former before, in the latter after thirty^ 
whence it may be concluded that a mobile nervous system is neces- 
sary to its origin. 

Pathological Anatomy. — The changes characteristic of exophthal- 
mic goitre are by no means striking. The veins and arteries of the 
thyroid show great increase of size and thickness, and the gland 
itself is unaltered, or in the condition of simple hyperplasia, or cystic ; 
but the last-mentioned state has no relation to this disease. A consid- 
erable increase in the fat behind the eye has been observed ; the mus- 
cles are affected with fatty degeneration (one case) ; the ophthalmic ar- 
tery is atheromatous (one case) — but these are probably only accidental 
changes. Some structural alterations have been found, in a majority 
of cases, in the sympathetic ganglia, and especially in the inferior gan- 
glion. Both sides may be affected, or one only, and the amount of 
disease varies greatly. The heart in most, if not all, cases is damaged 
variously, but these changes are not a part of this disease, and are en- 
tirely accidental. 

Symptoms. — In one of the author's cases the first symptom (pro- 
trusion of the eyes) was perceived by the patient on going to the 



750 



DISEASES OF THE NERVOUS SYSTEM. 



mirror in the morning. She had been subjected to a great shock the 
previous evening. Usually the onset of the disease is gradual, so that 
there are really two types, the acute and chronic. The acute cases 
may run their whole course in a few months. The initial symptom 
may be any one of the four great characteristics, but palpitation is 
most often the first departure from health. The increased action of 
the heart is at first paroxysmal, with intermissions during which the 
rate is normal ; but the intervals shorten until the heart-beat is always 
above normal, with paroxysms during which marked acceleration takes 
place. When the acceleration attains its maximum, the ordinary rate 
is from 90 to 120, but during the exacerbations 160, even 200, may be 
reached. A soft-blowing murmur is usually audible at the base, and 
propagated along the great vessels, and a stronger, whirring, blowing 
murmur is to be heard over the carotids and the thyroid ; an epigas- 
tric and sometimes hepatic pulsation may be detected. The vessels 
of the neck and of the thyroid may be felt pulsating strongly, the 
thyroid almost as an aneurism. The gland enlarges, one lobe^ — the 
right in the author's experience (six cases) — twice as often as the 
left ; but ultimately the whole of the organ, in several months usually, 
after the increased pulsations have begun. In very rare cases no en- 
largement of the thyroid has occurred. Sometimes the goitre is the 
first symptom observed. It is elastic, rather soft, and has a distinct 
thrill like that of an aneurism. It never attains a very great size, 
reaches its maximum in a few days or weeks, and fluctuates greatly in 
its dimensions. During the exacerbations in the action of the heart it 
enlarges, and subsides correspondingly after the attack is over. After a 
time it becomes firmer, and remains uniform in size. This change is 
due to the fact that the variations in the volume of the gland are pro- 
duced by the varying caliber of the vessels, and, when hyperplasia of 
the gland-elements occurs, the fluctuations in size are no longer possi- 
ble. Very great changes in the thyroid may take place, due entirely 
to accidental causes. Thus it enlarges in pregnancy, and it may take 
on cystic and calcareous degeneration. Exophthalmus may be the first 
symptom, as in one of the author's cases, but usually this comes on 
after the goitre. It may begin in one eye, but it is very rarely con- 
fined to one, and usually one eye protrudes more than the other. It 
may not occur at all in a case otherwise well marked, but this is un- 
usual. The degree of protrusion varies from a slight, staring expres- 
sion to the actual dislocation of the eye on the cheek, and it increases 
during the paroxysms of active palpitation, and diminishes in the inter- 
val. A very important diagnostic point is the incoordination in the 
movements of the upper eyelid and of the ocular globe. If a patient 
be told to look at her feet, the upper lid, it will be seen, does not fol- 
low the movement of the globe. As this does not obtain in the exoph- 
thalmus from any other cause, and as it may be present early in the 
history of the case, it may be very important. The nutrition of the 



EXOPHTHALMIC GOITRE. 



751 



cornea may suffer, and conjunctivitis is an ordinary complication. 
More or less fever occurs during the course of this disease, and a very 
considerable subjective sense of heat is felt. The rise of temperature 
is from one to three degrees of Fahrenheit, and a considerable increase 
of sweat is observed. Pigment deposits and pityriasis versicolor have 
been observed by the author in some cases, and other trophic affections 
of the skin have been reported by Bulkley, of New York. Changes in 
the disposition are constantly observed. The subjects of this disease 
are nervous, apprehensive, irritable, and lachrymose. Vertigo, wake- 
fulness, tremors, headache, impaired memory and power of application 
are often experienced. The appetite is usually poor, digestion feeble, 
vomiting readily occurs, and a more or less rapid decline in flesh and 
strength takes place. A marked degree of pallor is usually observed. 
The blood is anaemic, and amenorrhoea is present in most cases. 

Course, Duration, and Termination. — Acute cases going through a 
full development and decline in a few months are very exceptional. 
It is an essentially chronic malady, and years are occupied in its vary- 
ing phases. Recovery may ensue within six months, but usually it is 
not complete, and the symptoms develop again. The most important 
lesions occurring are dilatation of the cavities of the heart, and death 
as the ultimate result of the disturbances in the circulation. Tubercu- 
losis is apt to supervene, and some cases are carried off by intercurrent 
inflammatory affections. A favorable termination may be looked for 
when the general health is good, the thyroid unchanged, except by 
simple hyperplasia, and the heart is sound. 

Treatment. — The usual arterial sedatives possess but small value in 
the treatment of this disease. Good results have been obtained from 
belladonna and ergot. They should be administered for several months, 
and in full doses. The anaemia, which is so pronounced a symptom, re- 
quires iron. Traube achieved great success by a combination of quinine 
and iron. The author has had good effects from quinine, belladonna, 
and ergotin, in combination. Galvanization of the cervical sympa- 
thetic and the pneumogastric, by placing the anode under the ear and 
the cathode at the epigastrium, the author has found to be of the high- 
est efficiency. While the current is passing, the action of the heart be- 
comes less tumultuous, the protrusion of the eyes diminishes, and the 
thyroid shrinks somewhat. Besides the stabile application just indi- 
cated, labile applications should be made over the thyroid, and a 
weaker current should be applied to the eyes. While the galvanic ap- 
plications are making, 'the remedies suggested may be used internally. 

MYXCEDEMA. 

Definition. — The term myxoedema is compounded of two Greek 
words — /Au^a, mucus, and otSyjixa, a sioelling — and is applied to a pro- 
gressive disease, characterized by the occurrence of an apparent cedema. 



752 



DISEASES OF THE NERYOFS SYSTEM. 



produced by the deposit in the textures of a mucoid substance, and 
by changes in the mental condition. The first account of it was 
given by Sir William Gull,* in a paper with the following title : " On 
a Cretinoid State, supervening after Adult Life in Women." The 
term myxoedema was proposed by Dr. William M. Ord, f who also 
gave the first correct, although by no means complete, account of the 
apparent oedema. 

Causes. — The disease was at first supposed to occur in women only, 
and at the middle period of life, or about the climacteric. Dr. Mor- 
van, \ who has made a collection of fifteen unpublished cases, reports 
one case as occurring in a man ; Dr. Andrew Clark, of London, has 
met with several cases in men ; and the author has now a perfectly 
well-marked case in a man of forty-two. The original statements in 
regard to the age must also be modified. A case has recently been 
observed in a girl of eleven, and in Morvan's collection the youngest 
was twenty-two. The conditions producing the disease are not well 
understood. Alcoholism, syphilis, metallic poisoning, have not been 
concerned in the cases thus far reported. Nine out of fourteen oc- 
curred in women at the climacteric period. Prolonged lactation has 
appeared to have a causative influence in a few cases, domestic worry 
has been alleged in others, and living in damp, unhealthy habitations 
has apparently produced the disease in a few instances. 

Pathological Anatomy. — The essential condition of myxoedema is 
an overgrowth of the connective tissue, associated with a peculiar form 
of degeneration. The cement substance, containing more or less mu- 
cin in the normal state, is in this malady enormously increased ; the 
fibrillse undergo extensive hyperplasia and hypertrophic thickening, 
and the connective-tissue corpuscles multiply wherever there are con- 
nective-tissue elements — in the skin, raucous membranes, arterial tu- 
nics, glands, and nervous matter — there this peculiar change will be 
found to have taken place. The thyroid gland atrophies, so that 
its proper elements finally disappear, it may be, entirely. The over- 
growth of the connective tissue causes an atrophic change in all the 
tissues encroached on, and in this fact we have an explanation of the 
various symptomatic derangements. 

Symptoms. — The physiognomy of the subjects affected by myx- 
oedema is very striking. The face is puffy, pallid, and earthy in hue ; 
the lower eyelids are especially swollen by protuberant bladders, semi- 
transparent and cedematous-looking, so like that state in which they 
are in advanced renal disease that the first impression is the case is 
one of albuminuria ; the lips are swollen, the alae nasi thickened and 

* "Transactions of the Clinical Society of London," vol, vii, p. 180. 

f " On Myxoedema, a Terra proposed to be applied to an Essential Condition in the 
'Cretinoid' Affection occasionally observed in Middle-aged Women." — "Medico-Chirurgical 
Transactions," vol. Ixi, p. 57. 

X " Gazette Hebdomadaire," August and September, 1881. 



MYXCEDEMA. 



753 



protuberant, and the cheeks have a pinkish flush, terminating abruptly 
just below the orbit. There is no pitting of this apparently oederaa- 
tous face ; the skin has a rather doughy feel, is thick, resistant, and 
at the same time has a certain elasticity. The skin is generally dry, 
rough, and scaly, having a somewhat translucent aspect, and is with- 
out perspiration. The hands assume a peculiar shape, become square 
or " spade-like," as entitled by Gull, and the fingers are blunted, short, 
and somewhat clubbed. 

The thyroid gland, in sharp contradistinction from the condition 
in cretins, is either much smaller than normal, or has entirely disap- 
peared ; but the connective tissue of the subclavian triangle is, on the 
other hand, tumefied and more or less elastic. 

As the changes in the connective tissue include the neuroglia, it is 
not surprising that nervous derangements accompany the other symp- 
toms. The expression of the subjects of this disease is heavy, stupid, 
and somewhat sad ; the speech is slow and hesitating, if not incorrect ; 
the voice monotonous, and the manner that of a person having an in- 
active, if not feeble, mind. The memory is impaired, the judgment 
uncertain, and the mental operations in general below the usual capa- 
cit}^ This depression in the mental corresponds to the enfeebled state 
of the motor and sensory functions. The muscular movements are 
slowly executed, more or less uncertain, without being actually inco- 
ordinate, and hence the handwriting, as well as the gait, become irreg- 
ular, or awkward, without being otherwise perverted. There is a 
certain stiffness and clumsiness of the walk, without ther« being any 
actual loss of power, and more time is consumed in executing given 
movements than was usual in health. The same slowness and clumsi- 
ness are observable in all the mental operations. The response to a 
question is slow, partly in consequence of the tardy receptivity of the 
impression from without, and partly in consequence of the sluggish 
movements of the ideational centers. 

The respiration is slow, the action of the heart rather depressed 
and comparatively feeble. The temperature of the body is habitually 
from a half to one degree below normal, and a subjective sense of 
chilliness is nearly constant. A feeling of fatigue is nearly always 
present, and exertion increases it. Active movements soon exhaust 
the strength, and breathlessness follows on moderate exertion. The 
nutrition of the body is poor, the appetite feeble, and the digestion 
languid. A peculiar and very persistent taste — bitter, sweet, or mawk- 
ish — is a frequent symptom. The hair has a dry and unhealthy look, 
and is apt to fall out to a less or greater extent, becoming very scanty 
at last. The nails are brittle, curved, and irregular in growth, and the 
teeth decay early. The skin being without its natural secretion, the 
kidneys are not opposed in function, and hence the amount of urine 
is increased. As the functions in general are sluggish, this increase 
of urinary water must be connected with the lessened activity of the 
60 



754 



DISEASES OF THE NERVOUS SYSTEM. 



sudoriparous glands. The change in the condition of the urine, at an 
early stage of the disease, consists entirely in the increased excretion 
of water, there being neither albumen nor sugar present. With the 
further progress of the mucoid changes in the kidney, and the en- 
croachment of the connective tissue on the Malpighian tufts and 
tubules, the urine becomes albuminous. 

The uterine functions do not appear to be affected by the progress 
of the disease. If the malady appears at the climacteric period, the 
disturbances belonging to this period are not necessarily related to the 
development of this affection. 

Course, Duration, and Termination. — Myxcedema pursues a pro- 
gressive course, and has apparently been little affected by remedies. 
It develops slowly, the appearance of oedema being secondary to the 
anaemia. As it develops there is a constantly increasing weakness. The 
mind, at first torpid, becomes a prey to hallucinations. The temper, 
at first amiable and slow to anger, becomes irritable. At or near the 
close of the malady stupor comes on, and the end may occur in coma. 
As the changes progress in the various organs concerned in assimila- 
tion, the nutrition fails, the muscular force is quickly expended, fixed 
attitudes are maintained with difficulty, and all exertion is finally 
accomplished with great difficulty. The blood becoming watery, and 
the urine albuminous, a true oedema finally comes on. The whole 
duration of an uncomplicated case is about six years. Intercurrent 
diseases may end life meanwhile. Death may occur from exhaustion, 
by uraemic poisoning, or by cerebral coma. 

The prognosis, from our present stand-point, must be regarded as 
unfavorable. Nevertheless, increasing experience justifies the expres- 
sion of some confidence in the good effects of remedies now utilized 
in the treatment. 

Therapy. — Recognizable causes — as child-bearing, lactation, the 
affections incident to the climacteric period, bad hygiene, depressing 
moral emotions — should, as far as possible, be removed. 

Remedies belonging to the group of nervous tonics — as arsenic, 
iron, massage, faradism, and a generous diet — have in many cases 
done great good, and in a few have effected cures. Pilocarpus and 
warm baths have been very useful in some instances, the effect of both 
being to promote the action of the sudoriparous glands. Ord I'eports 
that in three cases the disease almost wholly disappeared under the use 
of pilocarpus — ten to sixty drops of the fluid extract being given four 
times a day. 

The author believes that the method of treatment known as central 
galvanization will prove to be an important aid to other measures. In 
a case now under observation, great improvement has followed the use 
of extract of ergot and arseniate of iron — two grains of the former, and 
one tenth of a grain of the latter, three times a day. 



GENERAL OR CONSTITUTIONAL DISEASES, 



ERUPTIVE EEYERS. 



VARIOLA. 

Definition. — Variola is an eruptive disease characterized by tlie 
presence of pustules, which make their appearance at the end of the 
third exacerbation of the initial fever, when the temperature declines, 
but this period of diminished fever or of apyrexia is followed by a sec- 
ondary fever, or fever of maturation. Small-pox, or pocJc, is the name 
in common use, which was formerly employed in contradistinction to 
the big pock, or syphilis — the word "pock" rnQd^mng pustule. 

Causes. — Small-pox prevails under all conditions of soil and cli- 
mate, its distribution at the present time being regulated by the de- 
gree of protection afforded by vaccination.* It occurs at all ages, 
and even the foetus in utero is attacked, and it may be so early as the 
fourth or fifth month of utero-gestation. Both sexes appear to be 
equally susceptible. Race exercises an influence which is quite de- 
cided — the dark races, negroes especially, possess a peculiar liability. 
During the actual existence of typhoid fever, scarlet fever, and measles, 
there is an immunity against the small-pox poison, and the susceptibil- 
ity of individuals varies at different times. As a rule, those who have 
been attacked once possess complete protection against future seizures, 
but there are numerous exceptions. The author has met with examples 
of small-pox occurring twice and three times in the same individuals, 
and notwithstanding vaccination. The susceptibility to a new attack 
may be acquired in a few months, but usually not until many years 
have elapsed. Mild attacks are apparently less protective than severe 
ones against future recurrence of the disease. Small-pox is spread by 
a peculiar virus whose nature is unknown. It is true, minute organ- 
isms on which the toxic activity is supposed to depend have been found 
in vaccinia, and also in the pustules of variola, but their position, as 

* "Traite de Climatologie Medicale," op. cit., vol. iv, p. 870. 



756 



ERUPTIVE FEVERS. 



accidental or causative, has not yet been made out. The transparent 
fluid of the pustules, before it becomes yellow and turbid, is most 
active, but the dried pustules are only less active. The morbific prin- 
ciple is not confined to the patient, but diffuses in the atmosphere about 
him, and extends a variable distance. Ventilation and large air-space 
dilute the poison ; hence a close room, with a number of persons, 
especially having small-pox, occupying it, concentrates the poison, 
making communication more certain. There is no period, from the 
initial fever to the final desquamation, at which the disease may not 
be communicated to the susceptible, but the stage of suppuration is 
the most virulent. All articles which have been about the person or 
bedding of the patient, especially those having a rough surface to 
which it may adhere, may retain the poison for a long time, and it 
may be conveyed from the patient, and from his bedding or clothing, to 
the clothing of another. The bodies of those dead of variola com- 
municate the disease, probably until the virus is destroyed by putre- 
factive decomposition. The persistence in the activity of the poison 
and its power to resist external influences are very great. When pre- 
served from the contact of air, it retains its activity for months and 
years. The spread of small-pox is affected by the immunity derived 
from attacks of the disease, but especially by the protective influence 
of vaccination. The exemption derived by the latter is less perma- 
nent than the former, and in many cases terminates after some years. 
It happens in this way that every few years a part of the population 
of civilized communities reacquire their susceptibility to the poison, 
and furnish the material for an epidemic. 

Pathological Anatomy. — The most important changes are those con- 
cerned in the formation of the pustules. The first step is the appear- 
ance of a small hyperiemic spot in the entire thickness of the derma, at 
and through a papilla. A swelling ensues in the part, especially in the 
outer layer of cells of the papilla, and pushing up the epidermis forms a 
papule. An exudation of a transparent fluid now takes place from the 
papillary layer, which, pushing aside the cells and the epidermis above, 
forms a vesicle. The cells are separated into groups, and not from each 
other, are compressed by the exudation, form an apparent network, 
in the meshes of which the lymph is contained.* While the upper 
cells of the papilla and the epidermis are engaged in the formation of 
the vesicle, the papillte themselves are swollen by enlarged and tor- 
tuous vessels, and by an exudation of serum. A central depression — 
an umbilication — forms in the vesicle, which is perforated by a hair- 
follicle, or the duct of a sweat-gland. This is due to the fact that the 
epidermis is continuous with the hair-follicle, and the duct of the 
sweat-gland also, so that this portion of the vesicle can not rise — in 

* " Untersuchungen zur Anatomie des Blatternprozesses," von Dr. H. Anspitz und Dr 
S. Basch, in Virchow's " Archiv," Band xxviii, p. 337, et seq. 



VARIOLA. 



757 



fact, the accumulation takes place around it — whence it follows that a 
central depression must exist. Pocks without being so situated — not 
perforated by a hair-follicle or sweat-gland — also have this umbilica- 
tion. Under these circumstances, we may adopt the explanation of 
Anspitz and Basch, who hold that this appearance is due simply to the 
more rapid swelling of the periphery of the pustule. When fully ripe 
the umbilication disappears, to reappear again in drying, owing to the 
more rapid desiccation of the center. In the case of confluent variola, 
the adjacent papilla may become inflamed, and partial necrobiosis oc- 
cur, causing great destruction of tissue. There is nothing peculiar 
and distinctive in the hsemorrhagic form, this condition being due 
merely to the substitution of blood for serum. The haemorrhage may 
be confined to the pustules, or may extend into the neighboring pa- 
pilla, and, in the worst cases, the whole cutis and subcutaneous tissue 
may be infiltrated with blood. Pustules are formed on the mucous 
membrane, and simultaneously catarrhal, croupous, or diphtheritic in- 
flammation takes place. The mucous membrane nearest the external 
skin, and most exposed, is most certainly and severely affected. The 
nose, tongue, tonsils, palate, and pharynx, and the orifice and internal 
portion of the Eustachian tube, are more or less infiltrated with pus ; 
the tongue loses its epithelium to a considerable extent, and pustules 
extend down the trachea to the bifurcation, and also to a short dis- 
tance down the oesophagus. The liver, spleen, kidneys, and heart are 
affected by granular and fatty degeneration, and in the haemorrhagic 
form there are numerous haemorrhages and ecchymoses throughout 
the body — in the serous and mucous membranes, and in most of the 
viscera. 

Symptoms. — The period intervening between the reception of the 
materies morbi and the outbreak of the malady is called the period of 
incubation. This is not a fixed period, although tolerably constant, 
the variations being due probably to the differences in susceptibility, 
to the action of the poison. The most usual period of incubation is 
from ten to thirteen days (Curschmann), which is the time generally 
agreed on by the authorities, but in some instances it has been as 
short as five and as long as fourteen days. During the stage of incu- 
bation we may suppose that the multiplication of the poison is taking 
place, but there are no objective nor subjective sensations indicative 
of the process until the stage of invasion. This stage sets in suddenly 
with a violent rigor, only comparable to that of an intermittent, or of 
pneumonia. Sometimes there are several chills or several hours of chil- 
liness. Fever begins at once, and in a short time rises to 103° or 104"^ 
Fahr., at which it continues, there being a slight morning remission. 
The fever may rise higher after the first day, to 105°, even 106°, and 
continue at that rate until the period of eruption. The pulse is strong, 
full, and bounding, and ranges in adults from 100 to 140 ; in children 



758 



ERUPTIVE FEVERS. 



to 160, The action of the heart is strong and heaving, there is some 
difficulty of breathing, often considerable dyspnoea is present, the ca- 
rotids beat vehemently, the face is red, the eyes injected ; there are an 
intense headache and sleeplessness, or sleep is disturbed by frightful 
dreams. Appetite is entirely absent, thirst is incessant, and nausea 
and vomiting with constipation usually occur. There is present in 
all cases more or less pain in the back, but in the largest number this 
takes the form of agonizing suffering, the pain being at the same time 
acute, lancinating, shooting down through the hips and thighs into 
the lower limbs, and heavy, tensive, boring pain felt deeply in the 
spine. The pronounced backache is accompanied by the equally pro- 
nounced headache, which possesses similar characteristics. There may 
be some confusion of mind in the milder cases occurring toward even- 
ing, and in other cases active delirium, especially in subjects ad- 
dicted to alcoholic excess. It was a dictum of Sydenham, revived by 
Trousseau, that the mildness and shortness of the stage of invasion 
furnished a guide to the character of the attack. " When the erup- 
tion makes its appearance at the end of the second day or the be- 
ginning of the third, it is necessarily confluent ; when it appears at 
the end of three and a half to four full days, or is postponed to the 
fifth, it is certainly discrete " (Jaccoud). Although there is a mea- 
sure of truth in the former propositions, they are by no means exact. 
The author agrees with the dictum of Jaccoud. If the eruption ap- 
pears after four full days of the preliminary fever, it is never conflu- 
ent ; it is either discrete or coherent. Although definite conclusions as 
to the severity of the disease can not be drawn from the date of the 
appearance of the eruption, yet the severity of the symptoms during 
the stage of invasion does furnish a measure of the probable violence 
of the disease. Besides the regular phenomena belonging to the stage 
of invasion, there are certain inconstant symptoms which possess a high 
degree of importance. These are convulsions, delirium, and dyspnoea, 
which have been briefly referred to, and certain initial or prodromal 
rashes which have not thus far been discussed. Following the divi- 
sion of Curschmann, these rashes may be arranged in two groups, ery- 
thematous and hcemorrhagic. The erythematous form is general to 
the whole surface, and assumes either a scarlatinal or rubeolous appear- 
ance. The hsemorrhagic eruption consists of minute points of haemor- 
rhagic extravasation into the epidermis. When these are combined, 
the hsemorrhagic spots appear like petechige or an erythema. The 
favorite site for these initial rashes is the lower portion of the abdo- 
men, the genitals and thighs forming a triangle which has been desig- 
nated the triangle of Simon. " A brachial triano^le " is formed of the 
rashes along the side of the trunk, extending into the axilla, the inner 
side of the arm, and over the pectoral muscles. The erythematous erup- 
tions tend to spread over the whole surface of the body. These erup- 



VARIOLA. 



759 



tions or rashes of the stage of invasion are by no means constant in 
their appearance ; many cases and some epidemics are entirely free of 
them. In the last epidemic of small-pox, the author, then practicing 
at Cincinnati, saw a number of them, and it was common to hear re- 
ports of cases in societies of the coincident appearance and develop- 
ment of scarlet fever or measles and small-pox. They usually appear 
on the second day, but they may appear on the first or third. Their 
duration is short, the erythematous lasting from twelve to twenty-four 
hours, the hsemorrhagic a day or two or longer. The invasion stage of 
variola is sometimes diversified by the appearance of the haemorrhagic 
condition or diathesis [purpura variolosa), and this is often confound- 
ed with the comparatively innocent hasmorrhagic rash. Purpura vari- 
olosa sets in in the usual way with severe rigor and pains in the head 
and back, very high fever, and great prostration. In from eighteen to 
thirty-six hours a very intense scarlatiniform eruption spreads all over 
the body except the face. Petechi^e and considerable patches of haem- 
orrhage appear in the skin and vary in size from mere points to an 
irregularly rounded figure about an inch in diameter, which remain dis- 
crete or apart on the extremities, and confluent on the abdomen, form- 
ing irregular masses. The face swells and is red ; the conjunctivae 
are injected, and the eyes, apparently sunken in their orbits, are sur- 
rounded by large, dark rings formed by the effusion of blood into the 
lids. The tongue is swollen and coated with a heavy, yellowish fur, 
and the pharynx, tonsils, and palate are covered with a membranous 
exudation, which emits a horrible odor. A severe cough, with watery 
and bloody expectoration, comes on, and there are nausea and vomiting, 
with bilious and bloody evacuations, and offensive bloody stools. The 
urine contains a large amount of albumin, which presently becomes 
bloody and thick. If pregnancy exist, miscarriage takes place, and 
the patient is carried off with the severe and uncontrollable haemorrhage. 
The mind usually remains unaffected, though there may be delirium 
and coma, and death ensues somewhere from the third to the sixth day 
after the attack began. The body has a frightful appearance at and 
immediately subsequent to death ; it turns black and is bloated, the 
features being horribly distorted and swollen. In such cases death 
appears before the eruption can develop, or it is so obscured as not to 
be recognizable. 

Stage of Eruption. — The characteristic eruption makes its appear- 
ance at the end of the third exacerbation of the fever — usually on the 
evening of the third or the morning of the fourth day — and is seen first 
on the forehead, about the eyes and mouth, on the hairy scalp, and 
then extends to the body and the extremities. The eruption at first 
consists of a red point, effaced by pressure, slightly elevated, some- 
what hard, and rolling under the finger like a small shot in the skin. 
The manner of distribution of the eruption varies somewhat. There 



760 



ERUPTIYE FEVERS. 



are four forms in which the eruption may be arranged : the discrete, 
or each pustule separate and distinct ; the corymbic, or placed in clus- 
ters or patches ; the coherent, in which the individual pustules come in 
contact ; and the confluent, in which the pustules unite or flow together 
without a line of division between them. In the ordinary typical case, 
the eruption is completed and no new pustules make their appearance 
after twenty-four to thirty-six hours. They tend to locate about the 
hair-follicles, the orifices of the sebaceous and of the sudoriparous glands. 
On the second day of the eruption, and the fifth day, including the 
initial stage, the red point is enlarged and elevated into a papule. ^ On 
the third day of the eruption the papules are transformed into vesicles 
filled with a transparent, serous fluid ; the vesicles increase in size dur- 
ing the next day or day and a half, and on the fifth day of the erup- 
tion, and the eighth day of the disease, the serous fluid of the vesicle 
becomes milky and presently purulent. When the vesicle is fully de- 
veloped, a central depression or umbilicus appears, and at the bottom 
is seen a hair-follicle, or duct of a sweat or sebaceous gland, but many 
distinctly umbilicated are not around a hair-follicle or gland-duct, show- 
ing that this appearance is in part due to the more rapid development 
of the peripheral portion, as suggested by Anspitz and Basch. If the 
summit of the vesicle which now appears milky be punctured, a drop 
only of fluid will escape, because of the cellular arrangement of the 
body of the pustule. While the appearance of the eruption does not 
indicate suppuration in all the forms, except the confluent, until the 




Fig. 48.— Range of Temperature in Discrete Variola. 

eighth day, the fever of suppuration really begins on the seventh. In 
the confluent and the extensive coherent forms, the fever of suppura- 
tion may set in on the sixth day of the period of eruption. There 
may be, therefore, considerable variation in the duration of the stage 
of eruption. 

In the discrete form, a marked change takes place in the condition 



VARIOLA. 



761 



of the patient when the eruption appears. The intolerable headache 
and backache subside or disappear entirely, the fever abruptly falls 




Fig. 49.— Eange of Temperature in Coherent Variola. 

to normal, even slightly below it, the nausea ceases, and the patient 
within a few hours passes from a condition of great suffering to one of 
comfort. It is only in cases of varioloid, or of variola, with few pus- 
tules, that the defervescence is so sudden. In the more severe discrete 
cases, or coherent, the decline of temperature, although considerable, 
does not reach the normal, and occupies a day or two of a remittent 
type, with considerable exacerbations. In the confluent form there is g 
mere abortive attempt at decline of temperature without much change. 
The pulse falls correspondingly to the decline of fever. An eruption 
appears on the mucous surfaces simultaneously with that on the skin : 
on the conjunctiva, pharynx, larynx, and trachea, and causing lachry- 
mation, photophobia, difficulty in swallowing, and cough. In confluent 
cases the eruption may extend to the bronchi, to the intestine, urethra, 
and vagina. Yery serious results may be derived from the pustules in 
these situations. Besides the symptoms above mentioned, there may 
be a violent conjunctivitis, ulceration of the cornea and staphyloma, 
with intense photophobia ; constant flow of saliva, and dysphagia ; 
toneless voice, croupy cough, and suffocative attacks ; dysenteric dis- 
charges ; painful urination ; and a sense of burning in the vulva and 
vagina. In addition to these constant symptoms there are others 
that may be regarded as accidental. If stupor and delirium appear 
during the stage of eruption, these symptoms are of evil augury. If 
merely due to habits of alcoholic excess, they are less serious than if 
they arise spontaneously under an increased mobility or instability of 



762 



ERUPTIVE FEVERS. 



the nerve-centers, and changes in the composition of the blood. If 
there be maniacal delirium, with suicidal tendency, the result is usually 
death about the beginning of the stage of suppuration (Jaccoud). 

8tage of Suppuration. — A gradual increase in the number of pus- 
corpuscles takes place from the beginning of the vesicle, and the con- 
tents of the pustule are entirely purulent by the ninth day. At this 
time each pustule enlarges, and assumes a hemispherical form, its base 
broader and darker, and the skin around it becomes swollen and tume- 
fied. The broad red band surrounding each pustule is known as the 
halo. When the pustules are thickly set, the swelling is universal and 
the redness diffused. Under these circumstances the head is much swol- 
len, and the features distorted, so that the individual can no longer 
be recognized. This distortion is the more conspicuous about the 
eyes and lips, because of the quantity of loose connective tissue, per- 
mitting extensive oedema to take place. Certain parts are less trou- 
bled by the eruption, and notably Simon's triangle, which is the favor- 
ite site of the initial rashes. The eruption appears on the body and 
extremities after the face, and consequently is maturing in these 
places after it has matured on the face. The process of suppuration 
in the pustules is accompanied by a symptomatic fever. A chill, or a 
succession of chills, mark its onset in some subjects, but this remark 
is true of those cases only in which the appearance of the eruption was 
coincident with a defervescence of the fever, or at least with a consid- 
erable decline. When the fever has persisted from the beginning, it is 
increased by the suppuration, and assumes a somewhat different type, 
becomes remittent, the daily variations being as much as two degrees. 
The range of temperature and the pulse-rate, as well as the various 
kinds of disturbance accompanying the fever, are greatly influenced 
by the extent of the suppuration. The temperature will rise to 
104°, 105°, or 106° Fahr., and the pulse to 100, 120, 140, or higher. 
With the development of the secondary fever, there will appear all 
of the distressing sensations which marked the initial stage. The 
headache and backache again become severe, the whole surface of the 
body is full of the pain and irritation of the suppurating sores, there 
are great restlessness and wakefulness, and an active or low-muttering 
delirium comes on. Frequently the delirium is maniacal, and the pa- 
tients difficult to restrain : they jump out of the bed, or out of the 
window, or escape into the streets. In children, the heat and burning 
of the face are so great that they will scratch the parts, covering their 
hands and the bedclothes with blood, and greatly increasing the local 
inflammation. 

The drying of the pustules begins about the eleventh day — 
rarely earlier, more frequently later — and in the order which the 
eruption followed. The drying begins before the disappearance of 
the fever of suppuration, for, when the face-pustules have completed 



VARIOLA. 



763 



their evolution, those of the extremities are just suppurating. When 
the desiccation begins, a honey-like exudation is poured out on the sur- 
face of the pustules, which, drying, forms an adherent coating. The 
contents of the pustules also desiccating, a brownish scab results. Be- 
fore desiccation has taken place in the pustules on the posterior por- 
tions of the body, the matter which they contain is pressed out on the 
bedding and clothing of the patient, and, decomposing, a peculiar 
odor results, which to many persons has something distinctive, even 
diagnostic, about it. Owing to the thickness and hardness of the epi- 
dermis, the pustules on the hands and feet have a peculiar form and 
dry earlier, but are slower to separate. As the pustules dry, the red- 
ness and swelling of the skin subside, and the face begins to assume 
something of its natural appearance, albeit somewhat roughened, red- 
dened, and disfigured by the disease. Although the whole body is 
marked by cicatrices, the face is peculiarly disfigured. The pustules 
involving the true skin, and closely placed, extensive losses of sub- 
stance may occur, especially about the nose. Ulcers penetrating the 
cornea, protrusion of the lens, and various opacities, result. A de- 
pressed and radiated cicatrix, becoming whiter than the surrounding 
skin, is left at the site of every variola pustule. As the crusts are de- 
taching, there is often an intolerable itching, and injury is done by 
children who increase the area of inflammation by the violence of the 
scratching. Erysipelas may occur and furuncles form during the 
progress of the dermatitis. The hair usually falls out, and the nails 
sometimes drop off. 

OONFlIUENT VARIOLA. 

The description above given applies to the ordinary cases of small- 
pox : to the discrete, the corymbic, and the coherent. There are some 
peculiarities of other forms which require particular consideration. 
The approach of the confluent form is announced by the greater vio- 
lence of the initial or invasion stage, and by the earlier appearance of 
the eruption. When the eruption appears it spreads over the body 
quickly, and indeed, in some cases, it seems to be on the face, body, 
and extremities simultaneously. At once the papules approximate, 
and their entire formation is prevented by the closeness of arrange- 
ment, so that large numbers coalescing form immense vesicles filled 
with sero-pus. While the face and features are hidden under huge 
bullae of pus, the pustules on the rest of the body may be merely cohe- 
rent. The mucous membrane is attacked with similar violence ; the 
pustules flow together, and diphtheritic exudations spread over the 
fauces, pharynx, nares, and Eustachian tubes. The tongue is greatly 
swollen, and protrudes from the mouth. Pustules form in the larynx, 
the cartilages are invaded, abscesses develop, and oedema of the glot- 
tis ensues. The parotid and sublingual glands swell enormously. The 



764 



ERUPTIVE FEVERS. 



cornea is opened by ulcerations, and staphyloma results. Erysipelas, 
phlegmonous inflammation, and extensive suppuration may occur in 
those parts where the eruption is most confluent, and even gangrene 







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Fig. 50.— Eange of Temperature in Mild Confluent Variola. 



results in extreme cases. The systemic state, as might be expected, is 
quite in harmony with the condition of the skin and mucous mem- 
brane. During the initial or invasion stage, the temperature reaches 
the highest point human temperature ever attains, and declines but 
little, sometimes not at all, and always slowly when the eruption ap- 
pears, continuing at 104° to 105°. The stomach is very unsettled, and 
vomiting is incessant, scarcely anything being retained. The urine is 
scanty, and loaded with albumin. If the patient pass through the 
dangers of the invasion fever, the eruption and suppuration stages, 
there will occur in the stage of desiccation extensive losses of substance 
of the skin of the face, eyelids, and eyes, and of the scalp, so that very 
great deformity, with baldness, will result. 

HiEMORRHAGIO VARIOLA. 

It is important not to confound haemorrhage into the pustules, or 
hcemorrhagic variola, with purpura variolosa, which is the hsemorrha- 
gic diathesis superadded to the phenomena of variola. Again, the hsem- 
orrhagic rash of the invasion stage — merely petechias — is quite distinct 
from the other forms. There may occur, with haemorrhage into the 
vesicles, extravasations of blood into the adjacent parts. Only a por- 
tion of the eruption may be affected by haemorrhage into the pustules, 
or it may be general over the body. Blood may escape into the pap- 
ules, or not until the stage of vesicles is reached, but the most usual 
condition is for the haemorrhage to occur when the pustule is well um- 
bilicated. It usually takes place by degrees, beginning on the lower 
extremities. The mucous membranes of the mouth and throat are 
marked by extensive ecchymoses, and diphtheritic exudations spread 
over the tonsils, palate, and pharynx. With these troubles are associ- 



VARIOLOID. 



765 



ated a spongy state of the gums, and hsemorrhages from the nose,^ 
gums, kidneys, uterus, and, if pregnancy exists, abortion followed by 
metrorrhagia. The general condition corresponds. The profound al- 
teration in the composition of the blood manifest under these circum- 
stances is accompanied by very great prostration of the vital forces. 
But there are great differences in the gravity of these cases, as there 
are in the extent of the hsemorrhagic extravasations ; in some epidemics 
the hsemorrhagic pustules are not numerous, and the general condition 
not unfavorable. 

VARIOLOID. 

Varioloid is a form of variola modified by previous vaccination, by 
a former attack of variola, or by some special insusceptibility to the 
action of the poison. It is, however, at the present time, almost 
wholly the influence of vaccination, which so modifies small-pox as. to 
cause it to take the mild form or varioloid. The protective influence 
of vaccination, or of an attack of the real disease, is at first complete, 
but the longer the time which elapses from the date of the vaccination 
the less protective its influence ; but in many persons, it is true, this 
protection continues throughout life. It is a peculiarity of varioloid 
that it presents numerous points of departure from the typical course 
of variola. Thus the stage of invasion may be one or two days, or 
three or four ; and the temperature declines very abruptly at or just 
after the appearance of the eruption, and descends to or below nor- 
mal, and it remains at normal until the stage of suppuration, when it 
assumes a transient rise of not more than one or two degrees. The ini- 
tial or invasion rashes of the erythematous variety belong to varioloid, 
and not to variola, and the more decided the rash the less abundant 
the pustules. Great diversityand difference, as compared with variola, 
exist in respect to the manner of development and characteristics of 
the varioloid eruption. It does not always appear first on the face, 
but on the chest, abdomen, or extremities ; it may all appear simulta- 
neously over the body, or there may be a very slow eruption of the 
pustules. While the structure of the varioloid pustule does not differ 
from that of variola in respect to development, there are remarkable 
variations. The eruption, although it may apparently be as complete 
as variola, never goes through the development of the latter, and they 
abort at different stages. They may not proceed beyond mere pap- 
ules ; they may develop into vesicles and then dry up ; they may be- 
come pustules, surrounded by a red areola, but the surrounding skin is 
not swollen, and from the fifth to the seventh day of the eruption des- 
iccation occurs. The pustules containing a sero-purulent fluid dry up 
without discharging, and, although an hypertemic spot remains for a 
short time, no scar is left. The eruption on the mucous membrane is 
usually slight, and produces but little disturbance. 



766 



ERUPTIVE FEVERS. 



Course, Duration, and Termination. — The discrete, corymbic, and 
coherent forms are severe, according to the extent and number of the 
pustules, and pursue a course of great uniformity. The most formi- 
dable of all the varieties is that known as purpura variolosa — the 
hsemorrhagic condition or diathesis superadded to small-pox. Death 
takes place in this form before the characteristic eruption appears or 
has time to develop ; rarely do any cases live beyond the sixth day of 
the disease. The confluent form, although largely fatal, is not inva- 
riably so. The termination is usually by pneumonia, pleurisy, or peri- 
carditis, especially the last two. When recovery ensues, the conva- 
lescence is tedious, and interrupted by various complications, especially 
abscesses of the skin. Very often the termination is by pyaemia. The 
hsemorrhagic pustular form is characterized by great intensity of the 
lumbar pain, and by remarkably low temperature, which may persist 
throughout. On the other hand, the temperature through the initial 
stage and subsequently may be very high. This form is more pro- 
tracted than purpura variolosa, and almost as fatal. The mortality, 
however, is very much affected by the number of pustules into which 
hsemorrhagic extravasation has taken place. The author has in one 
epidemic seen at least four cases recover out of six of the hsemor- 
rhagic form, but the pustules of the face were chiefly affected. The 
course of small-pox is modified by various complications. Numerous 
points of inflammation exist throughout the brain and spinal cord in 
some cases. Serious complications on the part of the eye have already 
been mentioned, consisting of ulcerations of the cornea, panophthal- 
mitis, haemorrhage into the retina, etc. Chronic otitis, caries of the 
bones, and permanent loss of hearing result, and the voice is hurt by 
chronic inflammation of the larynx. The mortality is much affected 
by the age of those attacked : at the extremes of life, notably in in- 
fancy, the mortality is greater. In women, owing to the accidents 
growing out of pregnancy, the mortality is greater than in men. Al- 
coholic excess greatly increases the danger. All those circumstances 
lessening the vital power of individuals impair the power of resistance 
to the disease. The more extensive the eruption, as has been stated, 
the greater the danger. ISText to the extent of the skin affection, as a 
measure of prognosis, stands the pustulation of the mucous membrane. 
Diphtheritic affections of the throat and inflammation of the larynx 
are very dangerous complications. The duration of any case depends 
on the form, extent of the eruption, the complications, etc. An or- 
dinary case of discrete variola will not run its course under five or six 
weeks. 

Treatment. — We postpone vaccination, a means of prophylaxis, for 
separate consideration. We possess no means of treatment to modify 
the course or shorten the duration of small-pox. All specifics may be 
dismissed with the assertion that they have, one by one, proved worth- 



YARIOLOID. 



767 



less, from sarracenia to zylol. The treatment is therefore symptomatic. 
Assertions as to the value of special remedies, or plans of treatment, 
must be received with caution, since the almost universal practice of 
vaccination modifies the behavior of cases — effects which may be 
readily mistaken for the infiuence of the medication employed. When 
the case is one of varioloid, but little treatment is necessary. In the 
confluent form, treatment is as little important, because without effect. 
During the stage of invasion, the high temperature and the cerebral 
disturbance are the points to which we direct attention. To allay rest- 
lessness, delirium, and fever, bromide of potassium and chloral are the 
most efficient remedies. If the headache and backache are very in- 
tense, the hypodermatic injection of morphine should be practiced occa- 
sionally. The bromide, some believe, has the power to modify the erup- 
tion. When the secondary fever develops, the best remedies are quinine 
in five-grain doses, and bromide of potassium to allay cerebral excite- 
ment. So common is it for the delirium to assume a maniacal character 
that the utmost care is necessary to prevent accidents. Chloral is not 
advised to be given at this period by the stomach, because of its highly 
irritant effect on the fauces, but it may be given by the rectum. Mor- 
phine, or opium in some form, will be indispensable to relieve the pain- 
ful sensations experienced by the patient. Depression of the powers 
of life will be best antagonized by the free use of carbonate of ammo- 
nia and alcoholic stimulants. From the beginning, proper aliment is 
necessary. Milk, eggs, animal broths, oysters, and beef-juice, should 
be given regularly from the beginning, every three hours. Ice is al- 
ways grateful, and should be allowed freely. When there are many 
pustules in the mouth, ice should be held in the mouth as, much as pos- 
sible, and ice will best serve to allay nausea. If there is much vom- 
iting, the hypodermatic injection of morphine is the most efficient 
remedy to arrest it. An ice-bag to the head and to the spine will 
afford much relief to the pain. For the eruption on the face number- 
less expedients have been resorted to, with a view to prevent pitting. 
The French employ, and, as they think, advantageously, a mercurial 
plaster. It is probable that a mask of some unctuous material, thor- 
oughly applied to exclude the air, has a beneficial effect. The author 
has used with apparent advantage the glycerite of starch, freely ap- 
plied by a large brush several times a day. As the papules are about 
to develop into vesicles, the tincture of iodine should be painted over 
them thoroughly. There are good reports from this practice. Of all 
the local applications, there is nothing so serviceable, according to 
Curschmann, as water-dressings to the face and -hands. Cold com- 
presses are kept constantly applied. They not only give great relief to 
the local heat and burning, but diminish the swelling of the skin. If 
cold is not pleasant, warm applications may be used instead. For the 
mouth eruption, solution of chlorate of potassa, and, if there is much 



768 



ERUPTIVE FEVERS. 



fetor, of carbolic acid, is useful. Astringents may also be used with 
advantage — such as fluid extract of hydrastis, of eucalyptus, and sub- 
sulphate of iron. When the crusts are falling off, warm baths assist 
in detaching them, and also allay the troublesome itching. Inunctions 
of lard, of suet, of vaseline, after the warm bath, are more effective. 
All the excreta of the patient should be at once disinfected by carbolic 
acid, sulphate of iron, iodine, etc. The air of the apartment should 
be also disinfected by the vapor of iodine, or by sulphurous acid, and 
the halls communicating with the room not less so. All articles about 
the patient should be destroyed, and the apartment renewed in all re- 
spects. 

VACCINIA AND VACCINATION. 

Vaccinia, or coic-jyox, is a natural disease occurring in the cow and 
horse, and possibly some other animals. It is a vesicular disease, the 
eruption limited to the udder and teats, and occurs sporadically or as 
an epizootic. It seems to be peculiar to milch-cows, and is conveyed 
to others by the hands of milkers. It is the young cows who are 
chiefly affected, and the course of it is essentially the same, whether 
it arises spontaneously or is propagated by inoculation. In the natu- 
ral disease the period of incubation is usually three or four days, but 
it may continue from five to eight. The udder swells, becomes hot 
and tender, and hard papules, the size of a pea, appear at the base of 
or on the teat. When the disease occurs by inoculation, if there be 
a crack or an abrasion of the skin, a papule may develop as early as 
the fifth day, but, if the skin be unbroken, not until the eighth or ninth 
day. In three or four days after their first appearance, the papule has 
acquired a distinctly vesicular character, and a central pit or depres- 
sion is then to be se^en. In four days more, or in about eight days 
from the first manifestation of the papule, the formation is complete. 
They vary in number from two or three to twenty or more, and their 
usual size is about that of a dime. Their shape is somewhat influenced 
by their position : on the teats they are oval ; at the base of the 
teat round ; but both forms may appear on the udder, and on the teats 
they may be coherent, even confluent. Their color varies somewhat, 
but they usually have a shiny, glistening, metallic luster of the mar- 
gin, with a slate-colored center. They are surrounded by a narrow 
areola, pale-rose or damask-colored, and a band of induration. The 
color and tints of the vesicle and of the areola differ somewhat, ac- 
cording to color and texture of the skin. When the development is 
completed, at the end of eleven days, the lymph is abundant ; the cen- 
tral depression disappears, and instead there is a conoidal elevation. 
If it now burst or is opened, a quantity of a straw-colored or amber- 
colored lymph flows out ; but, if rupture does not take place, the lymph 
becomes turbid and purulent, and by the fourteenth day a crust of a 



VACCIXATION. 



769 



brownish-black, or rather mahogany, color has formed, the areola and 
the marginal band of induration subsiding. The crusts shrink, dry, 
and fall off about the twenty-third, day. The cicatrix is smooth, oval, 
or circular, according to the shape of the vesicle, and whitish in color. 
When the vesicles are handled, and ruptured as in milking, there will 
be seen large black scabs adherent at some points, and a raw, bleeding- 
surface at others, while here and there appears a properly formed 
vesicle. Examination of the structure of the vesicle demonstrates a 
number of partitions, and the lymph contained in the spaces formed 
by them — an arrangement just like that of the small-pox vesicle. The 
vaccine disease may be produced by inoculation with lymph taken 
from other cows suffering with the disease ; with the lymph of horse- 
pox, which is identical with the cow-pox ; with humanized lymph, or 
retro-vaccination ; and by the matter of small-pox, or variolation. 
The latter process has given origin to a good deal of controversy, 
owing to the difficulty of inoculating cows with the matter of variola, 
but it has been accomplished a number of times, the results being in 
all respects the same as ordinary vaccinia — so that the vaccine dis- 
ease, as Jenner originally maintained, is variola, modified, by transmis- 
sion through the system of the cow. 

Vaccination. — It would be a misapplication of space to discuss the 
value of vaccination as a means of saving men from the greatest 
scourge of modern times. Shall humanized, Jennerian lymph, or bovine 
virus be used to vaccinate ? The following facts seem conclusive in 
favor of the latter : The carelessness in selecting and. storing the hu- 
manized lymph and the vast numbers of transmissions have impaired the 
quality of the product, and, although, so far as the development is con- 
cerned, it still conforms to the original type, its protective influence 
seems less. Again, owing to carelessness in collecting the lymph, the 
syphilitic virus has been inoculated with vaccine. Much prejudice has 
been excited against humanized lymph, and hence any unavoidable acci- 
dent occurring from its use would be referred to a sup230sed impurity. 
For these reasons bovine lymph is preferable. The objections to the 
latter are, that it is less certain, and that its action is violent, a good 
deal of constitutional disturbance being caused by it. The lymph 
should be preserved on quills, or ivory points ; and, if transported a 
long distance, in hermetically sealed tubes. It may be mixed with 
glycerine when intended to be kept in sealed tubes some time. When 
vaccination is performed with humanized lymph, it is preferable to use 
that of the fresh vesicle on the seventh or eighth day — or " arm-to- 
arm vaccination." The author has used successfully a number of 
times lymph that had been transported from Germany. The lymph 
is obtained from the vesicle of the seventh or eighth day, by carrying 
an incision around the outer border of the vesicle so as to open the 
several chambers of which it is composed, care being taken not to cut 
51 



770 



ERUPTIVE FEVERS. 



or injure the skin. With a fine pipette the lymph may now be with- 
drawn, and mixed with two parts of glycerine and two of distilled 
water, and preserved in capillary tubes, sealed hermetically with seal- 
ing-wax. The utmost care should be exercised in the selection of the 
children furnishing the lymph, and in the stock from which the virus 
is derived. In practicing vaccination, the skin should be rapidly and 
carefully scraped until the true skin is reached, and it is ready to bleed. 
The lymph may now be brushed over this surface with a camel's-hair 
brush. Another mode is to make three or four horizontal and trans- 
verse cuts about four lines long, or to insert the virus on the point of 
a knife by a single puncture. A little blood, but not much bleeding, 
should be caused by the cuts or punctures. Three or four points 
should be selected on the arm or leg for inserting the virus, and far 
enough apart so that the areola — certainly the vesicles — can not coa- 
lesce. If the vaccination " takes," a papule makes its appearance on 
the third day at the site of the puncture or incision ; on the sixth day 
a vesicle has formed, of a bluish-white color, having a raised border 
and a central depression ; on the eighth day it is fully formed, dis- 
tended with lymph, and a reddish areola surrounds it, which widens 
to two inches or more, and there is very considerable induration of 
the skin and subcutaneous areolar tissue. The areola begins to fade 
on the tenth day, and the contents of the vesicle become turbid, yel- 
lowish, and thick, begin to dry, and by the fourteenth day a brown, 
mahogany scab or crust has formed, but is not detached until about 
the twenty-third day. A genuine crust is circular, has a rounded and 
elevated border, a central cup or depression, and it has a dark-brown 
or mahogany color. The cicatrix left is circular, depressed, radiated 
and foveated, and is usually permanent, becoming after a time paler 
and whiter than the surrounding integument. More or less constitu- 
tional disturbance attends vaccination in children with a mobile ner- 
vous system : fever, when the vesicle is at its maximum ; restlessness at 
night, etc. An eruption of roseola may take place, or a papular erup- 
tion — a lichen — may appear. In scrofulous children an eczema maybe 
produced from the irritation caused by the development of the vesicle, 
or an otorrhoea may follow, etc. The lymph is usually held respon- 
sible for such accidents, but in strumous subjects the slightest wound 
may be followed by the same cutaneous troubles. As the protection 
is for a period which varies in different individuals, and, although for 
the whole life in most subjects when properly done, expires in others 
in a few years, it is necessary to repeat it at certain periods. Re- 
vaccination, practiced now in the great Continental armies, has had a 
remarkable influence in checking small-pox, and, as these statistics are 
on' an enormous scale and are accurate, the lesson taught us by them 
ought to be heeded. When there is some special exposure to conta- 
gion, vaccination should be practiced ; but as a rule, and entirely irre- 



VARICELLA, 



spective of contagion, revaccination should be done about the fifth 
year, after the second dentition, and at puberty. If properly done at 
these times, further vaccination will be unnecessary. 

VARICELLA. 

Definition. — Varicella is a febrile affection, characterized by the 
appearance of a vesicular eruption with the first elevation of tempera- 
ture, the vesicles drying up and falling off in from three to five days, 
the elevation of the temperature ceasing at the same time. It is known 
in common language as chicken-pox. 

Causes. — That it is an independent, specific affection, propagated 
by some peculiar poison, is now generally admitted. Its identity with 
varioloid has been and is still maintained by some authorities, but on 
insufficient grounds. It is a disease of childhood, and rarely attacks 
any one above ten years of age. It occurs both sporadically and as 
an epidemic. The mode of communication is unknown, and, although 
contagious, is not actively so. 

Pathological Anatomy. — The eruption is both discrete and corymbic 
— vesicles occur singly and in groups, and they vary in size from a 
pin's-head to a pea, reaching sometimes the size of a silver dime. They 
may be few in number, from ten to thirty, or they may be numerous, 
reaching one thousand. They consist of perfectly transparent vesicles, 
containing a clear, watery, sometimes yellowish fluid, faintly alkaline 
in reaction. They form on a spot which is slightly hyperaemic, and 
are surrounded by a faint areola, which is, however, often absent. 
They continue at their maximum not longer than a day, when they 
begin to be flaccid, dry in the center, and form a small, yellow, or 
brownish crust, which falls off in two or three days, leaving a faint 
reddish spot which disappears entirely in a few days, and sometimes a 
cicatrix, which, however, is shallow and very rarely permanent. 

Symptoms. — The eruption of the vesicles is the first symptom to at- 
tract attention, for there is no fever of invasion, and no prodromes that 
have been accurately studied. With the appearance of the eruption, 
a rise of temperature begins, but it is not often the case that the tem- 
perature rises high enough to be a subject for solicitude, the thermom- 
eter marking one, two, rarely three degrees above normal. The erup- 
tion first appears on the trunk, and then extends quickly to the ex- 
tremities. The hairy scalp usually contains a number. At first a spot 
of roseola appears, and on this is quickly projected a vesicle. Between 
the first crop of vesicles, on the next day, are seen a number of roseola- 
spots, and on these other vesicles make their appearance. But few 
appear on the face, and those chiefly on the forehead. The disease 
reaches its maximum on the second day and then declines, the fever 
disappearing, the vesicles drying up and dropping off. The vesicles 



772 



ERUPTIVE FEVERS. 



also appear on the mucous membrane of the mouth and on the geni- 
tals. The general symptoms are trivial. "With the fever there are 
thirst, anorexia, and constipation. Sleep is disturbed, and much itch- 
ing is complained of, especially in the scalp. The eyes are apt to be 
irritable, and it occasionally happens that vesicles appear on the con- 
junctiva, but the popular notion that chicken-|)ox is hurtful to the eyes 
is unfounded. 

Treatment. — There is nothing to be done but await the termination 
of the case by the natural mode. 

MSASLES— RUBEOLA. 

Definition. — Measles is an eruptive fever, with catarrhal symptoms 
referable to the broncho-pulmonary mucous membrane, self -limited, 
and terminating in about two weeks. 

Causes. — According to Lombard, measles appears in all parts of 
the globe, but is much less severe in the tropics and in extreme north- 
ern countries. It is a contagious disease, which may be communi- 
cated not only by immediate contact with the sick, but the morbific 
principle adheres to fomites, to articles of clothing, etc., by which it 
may be conveyed long distances, and by means of the healthy. It 
has been communicated by inoculation. The nasal mucus seems rich 
in the morbific principle. Measles prevails widely as an epidemic, 
and it occurs also in the sporadic form. Susceptibility to it is not the 
same in all individuals. Infants at the breast are not liable. The two 
sexes are affected with equal frequency. During an epidemic, not all 
exposed to the epidemic influence have the disease. One attack, as a 
rule, gives exemption from future attacks ; but to this dictum there 
are numerous exceptions. It is a disease of childhood especially, 
although infrequent in infants at the breast, and a few cases have 
been reported in which measles existed at birth. The atmospherical 
conditions which favor the production of bronchial attacks promote 
the epidemics of measles, which are therefore more numerous and 
severe in the fall, winter, and spring. The period of the disease when 
the contagion is most active is probably when the eruption is at its 
maximum ; but the contagious principle is present from the beginning 
to the end of symptoms. 

Pathological Anatomy. — The eruption of measles is in dark-red, 
sometimes rose-colored, spots, sharply defined, about the size of a pin- 
head to three pin-heads, disappearing on pressure, and immediately 
recurring when the pressure is removed. These spots have a lenticular 
shape, are usually discrete, and separated by tracts of normal skin, but 
may be coherent, forming an extended area of diffused redness, with 
punctations of deeper red, while the intervening skin is untouched. The 
spots are slightly raised above the general surface, and each spot maybe 



MEASLES. 



773 



surniounted with a very minute papule ; but this papule is not always 
present. The eruption of measles, with or without a papule, makes 
the skin rough. The spots appear on all parts of the body, but more 
on the face and trunk than on the extremities ; and they are more apt 
to cohere on the face and to be more abundant in this situation also, 
and of a brighter color. The exanthem appears first on the face, then 
on the neck, throat, upper part of the chest, and abdomen. It may 
develop fully on the face and continue there unchanged for a day or 
two Jbefore appearing elsewhere. The duration of the eruption at its 
maximum of development is not more than a half-day or a day, when 
retrocession goes on rapidly, beginning usually in the evening or at 
night, where the exanthem first came out, and in twenty-four hours 
the skin is pale. As the retrocession is going on, an exacerbation may 
occur, when the spots will appear again, almost to their original devel- 
opment ; but this is exceptional, and, if it happen, fading will soon (in 
a few hours) go on again. Some color remains for a few days at the 
site of the eruption — a brownish or yellowish stain — and, in the case 
of hsemorrhagic extravasation, which may take place in the skin during 
the height of the eruption, the petechial spots pass through the ordi- 
nary changes. More or less exfoliation takes place in the form of 
furfuraceous scales, and only from the spots ; large patches, like those 
of scarlet fever, are not known in measles. The mucous membrane is 
affected, as well as the skin, but in a different form. An intense 
hyperaemia of the nares, pharynx, palate, larynx, and conjunctiva, 
comes on with the initial stage. To this state of hypergemia are 
superadded dark-red spots, appearing with and corresponding to the 
skin exanthem, although not resembling it very closely. Minute 
papules are also seen to develop, but not in connection with the red 
spots. Retrocession of the mucous-membrane exanthem occurs a lit- 
tle earlier than that on the skin. In the measles of the war of the 
rebellion, intestinal changes were constantly observed, and consisted 
of enlargement of the solitary glands, more or less thickening of the 
patches of Peyer, and swelling of the mesenteric glands. The spleen 
was always enlarged by increase of the splenic pulp, and the kidneys 
were intensely hypersemic, the urine containing albumen. The blood 
was thin, the fibrin slight in quantity and feebly coagulable, the red 
corpuscles diminished and the white in excess. 

Symptoms— Invasion Stage.— The onset of the disease is announced 
by a feeling of weariness, muscular soreness, headache and backache, 
and a succession of irregular chills, the temperature then rising to 
100° or 101° Fahr. These symptoms, which mark the beginning of 
the prodromal or invasion stage, succeed to the incubation stage. 
From the period of exposure to the appearance of the eruption there 
are fourteen days, according to the most accurate observations. As 
four of these are occupied by the invasion stage, the period of incuba- 



7Y4 



ERUPTIVE FEVERS. 



tion must be fixed at ten days, or from nine to eleven days. During 
the incubation period there is no recognizable de2Jarture from the nor- 
mal, and the symptoms of the invasion stage come on rather abruptly. 
Together with the symptoms above mentioned as indicating the ap- 
proach of measles, there is an intense nasal, pharyngeal, and laryngeal 



Day 



102' 
100' 

96° 



4 


5 


6 


7 


8 


9 


10 


II 


12 






































— 




























































































































































































\ 


A 












































A 


































V 




V 




V 


A 






V 












... 





























Fig. 51. — Eange of Temperature ia Uncomplicated Measles. 

catarrh, which usually appears on the first, but may be postponed to 
the second day. The fever rises to 102°, where it usually remains for 
the first day or two, and its intensity furnishes a measure of the 
severity of the attack. On the second or third day — usually the sec- 
ond — a remarkable remission takes place, the temperature descending 
to normal or nearly so. On the evening of the third or the morning 
of the fourth day the fever rises again to the original height. With 
this decline in temperature, there ensues an improvement in the gen- 
eral condition ; the headache ceases and the general discomfort less- 
ens ; but the catarrhal condition does not moderate ; the nasal mu- 
cous membrane swells ; breathing through the nose is difficult ; there 
are frequent paroxysms of sneezing, and presently an abundant secre- 
tion of mucus is poured out from the membrane. The eyes are swol- 
len, the conjunctivce injected, the lids oedematous, and hot, scalding 
tears flow over the cheeks. During this time epistaxis is frequent, 
especially in children. By the third day the catarrh reaches the 
larynx, and then the voice becomes hoarse and husky, the cough 
harsh, resounding, metallic, stridulous. At first there is no expectora- 
tion, and only sibilant rales, but more or less prsecordial oppression 
and anxiety are felt. 

Eruption Stage. — The characteristic eruption of measles makes its 
appearance on the fourth day, and is rarely postponed to the fifth. In 
the milder cases the eruption appears on the morning of the fourth 
day ; in the severer cases, in the after part of the same day ; and it is 
seen first on the face, forehead, chin, and cheeks, spreading thence 
often, after an interval, over the body and extremities. The fever 
attains its maximum on the appearance of the eruption, or on the fifth 



MEASLES. 



775 



day, or there may be remissions — the maximum on the evening of the 
fourth, and a remission on the morning of the fifth. The color of the 
spots is deepest when the temperature is highest. The condition of 
the mucous membrane continues the same, but the cough soon be- 
comes easier because of the abundant secretion of mucus, soon assum- 
ing a muco-purulent character. Complications may arise at this point ; 
considerable bronchitis may develop ; diarrhoea comes on ; albumen 
(usually a trace) appears in the urine. These symptoms were usual 
and constant at this period of army measles. About the seventh to the 
ninth day the eruption on the face begins to pale, and the turgescence 
and redness of the visage lessen. With the retrocession of the erup- 
tion the temperature declines somewhat, and the normal is reached in 
a day or two. The defervescence may be sudden and without inter- 
ruption, the normal being reached in a day, or it may be gradual and 
varied by exacerbations and remissions. The slight desquamation that 
takes place is soon completed. Convalescence may be retarded by an 
irritable state of the intestinal canal. 

Course, Complications, and Anomalies. — The course and behavior of 
measles are much affected by the character of the epidemic influence, 
by the susceptibility of the individual and the hygienic surroundings. 
As it prevails in armies, measles comes to be a formidable disease, 
comparable only to typhoid ; sporadically, under favorable conditions, 
it is of very minor importance. In some epidemics many of the cases 
are very mild — cases of measles without the catarrh ; other cases, in 
which the catarrh and other symptoms are present, but the eruption is 
absent. On the other hand, some epidemics are characterized by the 
severity of the cases. Thus, in some epidemics, the hjemorrhagic diath- 
esis complicates many cases, and they present the usual phenomena 
significant of profound alteration of the blood. Before the eruption 
makes its appearance, or subsequently, hremorrhages take place in the 
skin from all the mucous surfaces, and into the parenchyma of organs. 
Profound adynamia sets in ; the pulse is rapid and weak ; the lungs 
are disabled by an extensive broncho-pneumonia ; the abdomen is 
tympanitic, and profuse watery and offensive stools are discharged ; 
the tongue is dry, the teeth covered with sorcles ; and low-muttering 
delirium ushers in death. A fatal result is not invariable, although 
usual in the haemorrhagic form. The eruption may be absent in the 
mildest cases ; it may pursue an irregular course, appear on the trunk 
before the face, remain on a very short time, or continue much longer 
than normal. Very high fever during the invasion stage, or great 
prostration, is significant of a severe case. The temperature fur- 
nishes the most certain guide to the actual state. Sometimes the 
eruption returns, the fever lights up, and all the phenomena of the 
disease are repeated. Various cutaneous eruptions may appear with 
the normal exanthem : as miliary vesicles, pustules, bullae, and urti- 



776 



ERUPTIVE FEVERS. 



caria. Serious complications on the part of the eye must be noted — 
such as conjunctivitis, keratitis, iritis, etc. The larynx is the seat" of 
ulcerations and erosions. Inflammation of the middle ear, succeeded 
by chronic otorrhcea, also takes place. But the most frequent and 
serious complications are capillary bronchitis, pneumonia, catarrhal 
pneumonia, etc. In some epidemics these complications are more 
numerous than in others, but the constitutional state and the hygienic 
surroundings are chiefly responsible. Capillary bronchitis and pneu- 
monia occur during and after the stage of eruption. In strumous sub- 
jects catarrhal pneumonia may undergo the transformation into case- 
ous, which is the explanation of the frequent occurrence of phthisis 
after measles. The constant association of enlarged follicles and intu- 
mescence of Peyer's patches in measles with the other morbid altera- 




Ftg. 52.— Eange of Temperature in Measles complicated with Catarrhal Pneumonia. 

tions characteristic of the disease, observed by the author in numer- 
ous autopsies, seems to justify his conviction that the former are 
really incident to the disease. An obstinate diarrhoea and dysentery 
(ileo-colitis) may occur at any point in the disease, but are especially 
troublesome from the period of retrocession of the eruption. Death 
is often due to this complication, or the convalescence is made very 
tedious. Simple uncomplicated cases of measles are free from danger. 
The indications that bode danger to life are an excessively high fever 
during the period of invasion ; sparsen^ss and dimness of the eruption 
while the general state is bad ; confluence of the eruption and hsemor- 
rhagic diathesis ; anomalies in the development of the eruption, the 
other symptoms being unfavorable ; capillary bronchitis, broncho- 
pneumonia, etc. ; intestinal disorders, severe ileo-colitis, etc. ; and 
cerebral complications. 

Treatment. — Mild cases require confinement in-doors or to bed, on a 
regulated diet, and a little paregoric to quiet a troublesome cough. If 



MEASLES. 



the temperature is high during the initial stage, and the cough trouble- 
some, a combination of aconite, ipecac, and opium is highly service- 
able (tinct. aconiti rad., 3 j, ext. ipecac, fl 3 ij, tine, opii deod., 3 iij. 
M. Sig. Six drops every hour or two). If the aconite fail to reduce 
the temperature (the remission occurring during the invasion stage 
should not be overlooked), a tea- to a tablespoonful of infusion of digi- 
talis may be given three or four times a day in addition. During 
the time of eruption, if the temperature is high, the skin should be 
rubbed every four hours with lard, or suet, or vaseline, or cacao-butter ; 
and, if the fever is moderate, three times a day. If the bowels are 
confined, a simple saline laxative ought to be given. Free action of 
the kidneys can be maintained by cooling drinks. The temperature 
of the apartment should be about 70°, and, while it is w^ell ventilated, 
all draughts must be excluded. The popular notion that measles re- 
quires a close room and blankets is a very pernicious one. The other 
extreme is equally dangerous. Such are the simple measures required 
in uncomplicated measles. When very high fever obtains through the 
prodromal stage, or subsequently, the antipyretic treatment most 
effective is the wet pack. The bed is protected by a rubber cloth, and 
over this is placed folded flannel of sufficient dimensions ; a sheet 
wrung out in water, each time beginning at 95° and gradually cooled 
to 80°, is laid on the flannel ; the patient is placed on the sheet and 
quickly wrapped up. This operation is repeated every half -hour until 
the heat is reduced. Besides the diminution of fever-heat, the w^et 
pack develops the eruption, and exercises a most favorable influence 
on the course of capillary bronchitis and pneumonia, whence it is to be 
especially commended when the high temperature is the result of the 
pulmonary complication. Quite irrespective of the temperature, local 
wet packs are of very considerable importance in the treatment of 
measles. The vapor of water allays the nasal stuffing and the sneezing, 
and tepid-water compresses best relieve the irritation of the conjunc- 
tiva. Tonsillitis and laryngitis are much benefited by enveloping the 
neck in a tepid pack, and frequently renewing it. Packs and com- 
presses are especially efficacious in the treatment of inflammatory affec- 
tions of the chest and abdominal organs. If baths can not be utilized 
to reduce temperature, quinine comes next in point of efficiency, 
but it must be given in antipyretic doses. Antipyrin may be used 
instead of quinine, and digitalis can be combined with these antipy- 
retics should a renal complication require it, and an irritable state of 
the stomach not prevent. In the hseraorrhagic form, quinine, the min- 
eral acids, tincture of ferri chloridi, turpentine, etc., are especially 
indicated. The most important, as it is the most frequent complica- 
tion, requiring careful therapeutical handling, is capillary bronchitis, 
with atelectasis, broncho-pneumonia, etc. The salts of ammonia, es- 
pecially the carbonate and iodide, are of immense value in this state. 



778 



ERUPTIVE FEVERS. 



The plasticity and adhesiveness of the exudation are lessened by them, 
and thus the access of air to the alveoli is favored. They may be ad- 
ministered in an emulsion together, or the carbonate may be dissolved 
in solution of the acetate. The vapor of water is an important adjunct 
to the other means for lessening the obstruction of the tubes, and hence 
steam should be freely disengaged in the apartment. The volatile 
expectorants are very serviceable, in that they diffuse out of the blood 
through the lungs, and thus act locally on the affected surface. The 
most efficient of these are eucalyptol and turpentine, especially the lat- 
ter, which is particularly indicated when the capillary circulation is 
feeble, the eruption pale, and the skin bluish. If the means resorted 
to fail to remove the obstruction in the capillary tubes, emetics become 
necessary. The subsulphate of mercury, alum, or sulphate of zinc, may 
be employed for this purpose — their repetition being determined by 
the results. Tartar emetic, which is often used, is greatly too depress- 
ing, and is dangerous. Apomorphine may also be given, but the re- 
markable effect which it now aud then has on the heart is a serious 
objection to its employment. In the intestinal complication the author 
has had the best results from the conjoined administration of Fowler's 
arsenic (two drops) and opium (deodorized tincture, five to ten drops) 
every four hours, and from sulphate of copper and sulphate of mor- 
phine to grain of the former, and y^g- to ^ grain of the latter, for 
adults, three times a day). Very careful alimentation should be direct- 
ed from the beginning, and should consist largely of milk, especially if 
there is a trace of albumin in the urine. 



ROSEOIiA— ROSTHBLN (GERMAN MEASLES). 

Definition. — By the modern German authors the term rubeola is 
restricted to this disease, which is usually called roseola in this coun- 
try. Following the course usually taken by American authorities, 
the term rubeola has been applied to true measles. Roseola is a self- 
limited eruptive disease, pursuing a course similar to measles. 

Causes. — This is a disease of early life, appearing equally in the 
two sexes, and propagated by infection. It does occur in adults, but 
less frequently. One attack procures an exemption against future at- 
tacks, but this is not an absolute rule. That a peculiar materies morbi, 
virus, or germ exists is probable, but thus far it has not been isolated. 

Pathogeny and Symptoms. — The eruption consists of rose-colored 
spots, the size of a pin-head up to three or four pin-heads, well defined 
and somewhat elevated, so that, when a number are placed near each 
other, the skin is distinctly rough. An hyperoemia of the papilla takes 
place, and of the adjacent cells of the derma above, and the redness in 
spots and the elevation of the hyperremic patch give the impression 
of roughness. The spots have a round or somewhat oval shape, dis- 



SCARLATINA. 



Y79 



appear on pressure, to return immediately when the pressure is with- 
drawn. The spots vary a good deal in size, and are rarely confluent or 
coherent. On the face, where they are most abundant, they do not 
flow together. They are nearly as abundant on the neck, chest, and 
abdomen. The eruption is quite abundant on the scalp, and extends 
freely over the extremities. The maximum development of the spots 
is about half a day, but the whole duration of their existence is from 
two to four days. A very slight discoloration remains for a day or 
two at the site of the spots, and very little, if any, desquamation takes 
place. From the period of exposure until the onset of the disease 
there are from ten to fourteen days. No symptoms occur until the 
eruption appears ; in other words, there is no prodromal stage, or inva- 
sion, or initial stage. There is no fever in a majority of the cases. 
The eruption appears first on the face and spreads thence regularly 
over the scalp, body, and extremities, in about the same order as 
measles. A light grade of catarrh comes on with or immediately suc- 
ceeds to the eruption, and there are redness, stuffing of the nose, sneez- 
ing, conjunctivitis, photophobia, etc., but all of these symptoms are 
much less severe than the corresponding symptoms in measles. More 
or less diffused redness, with punctations of deeper color, is observed 
in the mucous membrane of the fauces, pharynx, and larynx. Disor- 
ders of the intestinal canal or of the kidneys do not occur. In general 
the symptoms are so slight that children object to any restraint or 
confinement. Even in the few cases characterized by fever the symp- 
toms are by no means severe, and the complications which occur are 
usually unimportant. The prognosis is favorable, and the treatment 
need consist in nothing more than confinement in-doors and intelligent 
supervision. 

SCARLATINA— SCARLET FEVER. 

Definition. — Scarlatina is an acute, infectious disease, self-limited, 
characterized by a peculiar exanthem, an affection of the throat and 
albuminuria, and terminating in desquamation of the epidermis. 

Causes. — Scarlatina, like the other members of the group, is propa- 
gated by a peculiar poioon, which, by reason of the tenacity with 
which it adheres to articles of clothing, and other peculiarities, we 
have good grounds for holding is a solid. It is communicated by 
contact of the healthy with the infected, and by intermediation of 
various substances to which the poison adheres. It occurs both in the 
sporadic and epidemic form, but never arises spontaneously. The 
susceptibility to scarlatina is not by any means universal, and is less 
than to variola and measles. The time which elapses, from exposure 
until the objective signs of the disease are manifest, varies greatly, 
and is therefore very differently stated by authorities. The shortest 
period is that of a patient mentioned by Trousseau, in whom the dis- 



Y80 



ERUPTIVE FEVERS. 



ease appeared in a day after exposure. The other extreme is twelve 
to fourteen days. The most usual period is from four to seven days. 
The very slightest contact with the morbific principle suffices. It may 
be conveyed on or about the persons of the healthy to others at a dis- 
tance. That it may be dissolved in articles of food or drink is ren- 
dered highly probable by the epidemics following in the wake of milk 
distribution, of which several very instructive examples have been 
reported from England. The poison is probably contained in the 
skin and its excretions and epithelium, and also in the breath and 
exhalations from the throat. The period of greatest activity of the 
poison is at the highest point in the disease ; but it is present at any 
period, from the initial to the terminal symptoms. The susceptibility 
varies greatly, even in members of the same family, hence nothing is 
more common than for one member of a family to be attacked while all 
the rest escape. The susceptibility to it is increased by all causes low- 
erins: the vital forces : and hence those situated under unfavorable 
hygienic conditions are more apt to be attacked. Again, the suscep- 
tibility of the same individual may vary at different times. Within 
the first six months of infant life there is little liability to the disease ; 
but the susceptibility attains its maximum from the second to the fifth 
year, and declines slowly to the tenth, and after this more rapidly ; but 
it does occur in old age. The author had under his care a gentleman 
of sixty years of age, with scarlet fever, after caring for several of his 
children with the disease, and his was a typical example. Sex and race 
appear to have no influence. Negroes are said to be less susceptible 
than whites. The author believes that this is not true, the misconcep- 
tion having arisen from the difficulty of recognizing the disease in the 
negro. The disease but rarely occurs twice in the same individual. 
Those exposed anew, especially if brought into close relation, as in 
the case of mother and child, are apt to suffer from the angina, 
without experiencing any of the other symptoms. Cases of recurring 
scarlatina are by no means infrequent ; the author has seen two, in 
which, from one to three weeks after the close of the first attack, 
the whole phenomena of the disease were repeated, even to the des- 
quamation. 

Pathological Anatomy. — The eruption may be distinct, and around 
each spot a border of normal skin ; or it may be confluent, the whole 
surface of a vivid red, with punctations of a somewhat deeper tint. 
The eruption is due to an intense hyperaimia, which is limited to the 
area of the spots, but which is general when the spots coalesce. At 
its first appearance the eruption is less vivid than it becomes when 
fully developed. The spots appear first on the neck and upper part of 
the chest, then on the face, where they are also most perfectly de- 
veloped. They are nearly circular, are not elevated above the general 
surface, and do not therefore impart a roughness to the surface. They 



SCARLATINA. 



781 



are also nearly equal in size, and wlien discrete uniformly distributed, 
about as much of the integument being covered by the eruption as free 
from it. When confluent the whole surface is a vivid, brilliant red, 
marked, as may be seen on close inspection, by minute points of deeper 
color. The eruption having reached the maximum of intensity, remains 
stationary from a half -day to a day, and then slowly declines. When 
the eruption first appears on the face, the redness of the temples, 
forehead, and cheeks contrasts vividly with the pallor of the lips. The 
eruption may be partial, or occur in particular localities, leaving large 
portions of the integument uninvaded. Thus, it may appear on the 
face only, on the trunk only, or on the extremities, especially around 
the joints. The individual spots may be two or three times as large 
as the usual eruption. A miliary eruption of minute vesicles may 
appear on parts so situated as to sweat freely, and a very fine papular 
eruption on all parts, notably on the forehead. In some cases the cu- 
taneous appearances are diversified by hsemorrhages, and the formation 
of jDetechiae and vibices. Other forms of eruption may complicate 
the scarlatinal eruption, such as herpes, urticaria, pemphigus, and 
other vesicular and pustular affections. As the eruption disappears, 
boils may be observed, and more or less gangrenous sloughing may 
occur in low states of the sysfem, merely from pressure. Desqua- 
mation of the epidermis may succeed immediately to the erup- 
tion in a few days, sometimes in a few weeks, after it has disap- 
peared. The exfoliation of the epidermis occasionally, in severe cases, 
takes place several times, and it is usually general over the body, 
but the intensity of the desquamation is not a measure of the inten- 
sity of the exanthem. The desquamation may consist of fine fur- 
furaceous scales, and of large masses of exfoliation. The thick and 
hard epidermis of the hands and feet peels off in large flakes, and 
a cast of the hand or foot, like a glove or stocking, is not uncom- 
mon. Not unfrequently the hair and nails, and warts on the fin- 
gers, drop off. The skin is left red and sensitive by the desquama- 
tion, but its natural state is soon restored. Not less significant than 
the eruption is the affection of the fauces and of the pharynx. The 
mucous membrane of the fauces is intensely hypersemic, of a deep-red 
color, and marked by conical elevations — swollen follicles — which 
rarely in simple cases suppurate and discharge. In the severer cases, 
instead of a simple redness there is a more or less deep, livid redness, 
involving not only the fauces, but the whole mouth to the lips, the 
pharynx, and the nares. Besides the deep coloration, there are in- 
creased secretion and oedema of the mucous membrane, especially of 
the soft palate. The tonsils are also deeply inflamed, much swollen, 
and are liable to form enormous purulent accumulations. There is 
a still more formidable affection of the throat, in which, besides the 
changes mentioned above, there are oedema of the throat, deep-seated 



782 



ERUPTIVE FEVERS. 



inflammation of the tonsils, inflammation of the sublingual, submaxil- 
lary, and parotid glands, and simultaneous oedema of the areolar tissue 
of the neck, the whole forming a great mass of induration bulging out 
from the parotid region, and forming a broad band of induration filling 
in the whole space from the chin to the neck. The difticulties of the 
case are much enhanced by oedematous swelling and inflammation of 
the retropharyngeal connective tissue and that of the larynx. At the 
same time the tonsils may suppurate and slough, or become gangre- 
nous, and from the tonsils the suppurative and gangrenous process may 
extend in all directions, and extensive abscesses form in the neck, fol- 
lowed by immense sloughing and loss of tissue. A diphtheritic pro- 
cess may also ensue in the fauces ; and so common is it that a close 
relationship is supposed by many to exist between them. The tongue 
has a peculiar and very characteristic appearance. It is coated uni- 
formly, except at the tip and edges, with a heavy whitish or yellowish- 
white fur, increasing in depth toward the base. Through this coating 
the enlarged papillae project. On or about the third day an entire ex- 
foliation of the coating, and of the epithelium also, takes place, leaving 
the surface of the tongue raw and red, and roughened by the elevated 
follicles, presenting the ax)pearance of a fully ripe strawberry — whence 
the term ^'strawberry-tongue of scarlet fever." Troublesome affec- 
tions of the ear occur with those of the throat. Inflammation of the 
middle ear, perforation of the drum, and in severe cases caries, pre- 
ceded by periostitis of the squamous and petrous portions and of the 
mastoid process, take place. Also, in severe cases, the tissues about 
the ear externally are swollen, and pus dissects down the neck between 
the muscular planes. Inflammation of the larynx and oedema of the 
glottis during general dropsy, bronchitis, and pneumonia, are the 
lesions of the pulmonary organs occurring during the course of the 
severer cases of scarlet fever. Pericarditis, endocarditis, simple and 
ulcerative, with or without joint implication, are complications in many 
severe cases. There are no constant and uniform lesions of the diges- 
tive tube, pancreas, or spleen. The kidneys present, next to the skin 
and throat, the most constant anatomical changes. The tubules of the 
kidneys, like the skin, cast off their epithelium, which for a time may 
block the passages, until at length washed away by the urine (desqua- 
mative nephritis, tubular nephritis, etc.). Besides this, changes take 
place in the parenchyma (parenchymatous nephritis), already suffi- 
ciently described, succeeding to the other form, and occurring in the 
second to the third week. General dropsy and the accidents due to 
uraemia are usual concomitants of the kidney-disease. Closely con- 
nected with the condition of the blood due to the kidney-disease, if not 
dependent on it, are the attacks of inflammation of the serous mem- 
branes and of the synovial cavities of the joints. Meningitis, pleuritis, 
and peritonitis are the forms of serous inflammation, and acute rheuma- 



SCARLATIXA. 



783 



tism of synovial. The joint affection may consist only of a little pain 
and stiffness, or it may be a severe attack of rheumatism in which all 
the principal joints are affected in turn, peri- and endocarditis also 
occurring. 

Symptoms. — By the older authors,* scarlatina was divided into scar- 
latina mitis vel simplex^ scarlatina anginosa, and scarlatina maligna 
— scarlatina without any affection of the throat ; scarlatina with de- 
cided implication of the fauces and adjacent lymphatics ; scarlatina of 
the severest type with extensive suppuration, possibly gangrene. As 
these distinctions are rather artificial, we purpose describing first the 
ordinary, well-defined form, and mention subsequently the variations. 
The period of invasion is sudden and violent. A strong chill is 
the initial symptom in adults ; in children, a violent convulsion or a 
succession of them, or a severe attack of vomiting, with prostration. 
Headache of a very intense character, general muscular pains and 
high fever succeed to the chill. In a short time the temperature 
rises to 104°, 105°, or higher ; the skin is hot and mordicant ; the 
throat burns, and, on inspection, the palate, tonsils, and pharynx are 
red and somewhat swollen ; the tongue is coated with a thick yellow- 
ish fur. The fever is nearly continuous in type, and there are no 
strong remissions or intermissions, as in measles. The eruption makes 
its appearance usually at the termination of the first exacerbation of 
the fever — at the end of the first or beginning of the second day. It 
appears on the neck and upper part of the chest, and then on the cheeks 
and forehead, pale, rose-red, rapidly becoming brighter, and at first 
contrasting strongly with the white lips. Very quickly, in scarcely a 
half -day, has the eruption spread well over the body. In the more 
severe cases the eruption is not completed until the third or even 
fourth day. When the eruption is completed promptly, it is puncti- 
form, each spot distinct and surrounded by an area of normal skin ; 
when slower to reach its maximum, the eruption becomes confluent 
and diffused, the whole surface being of an intense scarlet hue. The 
tongue is thickly coated, but the coating with the epithelium peels off 
about the fourth day, leaving a red, raw surface, dotted with swollen 
follicles — the strawberry-tongue. There is no longer any vomiting, 
but the appetite is wanting, and there may be constipation or diar- 
rhoea. Severe headache is experienced in the more decided cases ; 
there are apt to be delirium at night and some confusion or somnolence 
through the day. On examination of the urine then, it is found to be 
scanty, high-colored, smoky, and contains more or less blood and albu- 
min. The eruption is barely completed before it begins to fade on 
those parts where it first appeared — certainly, it does not stand at its 
maximum longer than half a day to one day. The gradual disappear- 

* Gregory's " Lectures on the Eruptive Fevers," American edition by Dr. H. D. Bulk- 
ley, p. 151. 



784 



ERUPTIYE FEVERS. 



ance of the eruption is effected in two, three, or four days, and accord- 
ingly the time occupied by the eruption varies from three to seven 
days in its entirety. As the eruption fades away, the process of shed- 
ding goes on — at first, and for a short period, of a fine, furfuraceous 
desquamation, the shedding of large scales being subsequently the 
rule in most cases. The decline of the eruption is coincident with 
a diminution of the fever, and moderation of the general symp- 
toms. The fever declines by lysis — by a gradual lengthening of the 
remissions and shortening of the exacerbations. The pulse subsides 
with the fever, the delirium ceases, the skin becomes moist, suda- 
mina form, there is less and less trouble with the throat, and swal- 
lowing becomes easier ; membranous exudations are cast off, the ton- 
sils return to their normal size or nearly so, the tongue becomes moist, 
and its epithelium is rej^roduced ; the appetite returns ; the urine 
passes more abundantly, and carries off wasted and fatty epithelium, 
the albumin disappearing ; and thus, in about ten to twelve days 
from the beginning of the symptoms, convalescence is established. 
But few cases, however, go through so mild a course. The points 
on which the scarlatinal poison may exert peculiar force are various. 
The degree in which the cervical glands are involved differs greatly. 
In the mildest there is simply some slight tumefaction of the lym- 
phatics in the neighborhood ; in the severest, the whole space between 
the chin and chest i^ filled in, extensive suppuration occurs, slough- 
ing takes place, or more or less gangrene. Between these extremes 
there are numerous gradations of severity. The throat affection may 
be severe, and the exanthem light, and vice versa. It is sometimes 
the case that, when the throat affection is subsiding and the cer- 
vical glands are shrinking to the normal, a new disturbance arises 
in the glands ; they swell to a .considerable size, fever comes on, and 
convalescence is postponed. In the author's experience this reexcite- 
ment in the cervical glands is secondary to an exacerbation of the 
renal troubles. Great differences also exist in the amount of the kid- 
ney complication. The absence of objective evidences of kidney-dis- 
ease in the urine does not necessarily imply a healthy state of the 
kidneys. There are, however, very few cases in which a trace of albu- 
min is not visible. When the hyperaemia of the kidney occurs, the 
urine, besides being scanty and acid, has a smoky appearance, from the 
presence of altered blood-globules uniformly distributed through it. 
On cooling, the urine usually deposits a great quantity of urates, cast- 
off epithelium (Figs. 39, 40, 43), and casts containing much of the tu- 
bular epithelium. The epithelium and casts are found at, or about, the 
time desquamation of the skin has commenced. The amount of albu- 
min, when it first appears, is small. As the fever declines, and desqua- 
mation goes on favorably, the amount of urine discharged increases very 
much ; it assumes a watery appearance and its specific gravity is low ; 



SCARLATINA. 



785 



the albumin disappears, and in a short time the urine becomes normal. 
Parenchymatous nephritis usually develops during the desquamation 
period, in the third week, and rarely in the second. Then the urine 
becomes turbid from the presence of urates, blood-corpuscles, granular 
matter, casts, etc., is rather scanty and high-coloied, and throws down 
a great quantity of albumin. Xo absolute rule can be laid down as 
to the period when the most pronounced renal symptoms will make 
their appearance, but the time named above must be regarded as 
usual. The occurrence of renal changes is the signal for other dis- 
turbances. The lymphatic glands of the neck enlarge very much, the 
appetite goes, and there are nausea, vomiting, and constipation, and 
sometimes a severe diarrhoea. Violent headache, disorders of vision, 
hallucinations, illusions, muscular twitchings, and eclampsia are ex- 
perienced. The convulsions may be very violent in children, and one 
succeed another, with days of unconsciousness. The eyelids are 
swollen, and the legs pit on pressure. The urine may become very 
scanty, almost suppressed. The temperature may run very high, and 
the pulse be slow, falling to 60, 56, 50, and even lower, or the op- 
posite conditions may prevail — the temperature may be below nor- 
mal, and the pulse small, rapid, and feeble. As the symptoms become 
less grave, the urine flows more abundantly, but casts and epithelium 
may be present for some days, and albumin for weeks after the disap- 
pearance of any apparent disease. 

Course, Duration, and Termination. — In the mildest form of scar- 
latina there may be a simple hyperaemia of the fauces, some swelling of 
the submaxillary glands, a transient fever of two or three days' dura- 
tion, and the whole terminating in three or four days. In other cases 
there may be a pronounced rash, but no throat affection, no implica- 
tion of the kidneys, and a few days of a mild fever, desquamation 
being almost entirely furfuraceous. But these mild cases may be fol- 
lowed by albuminuria and general dropsy, acute rheumatism, and 
other complications. Sometimes the case seems of the mildest charac- 
ter at the onset, but develops into a state marked by all the charac- 
teristics of a profound toxasmia. Others begin in that way. At the 
very onset, headache, delirium, convulsions, coma, tetanic cramps, and 
rigidity of the extremities, uncontrollable vomiting, severe dyspnoea, 
and a rapid, very feeble pulse, indicate the severity of the blood-poison- 
ing, and death occurs in collapse before the eruption appears. As in 
every epidemic many of the mild, insignificant cases occur, so an occa- 
sional example of all that is most virulent in the scarlatina-poison is 
manifested in these cases, fatal within twenty-four hours of their ap- 
pearing. On post-mortem examination no lesions of importance are to 
be seen, because the changes are of a subtile kind, occurring chiefly in 
the blood. During the course of a perfectly normal case of the disease, 
symptoms of a very formidable character may come on, consisting in 
52 



786 



ERUPTIVE FEVERS. 



sndclen and great prostration of the powers of life, the pulse becomes 
extremely weak, the eruption fades, the skin grows cold, and death 
usually occurs in a few hours. In many cases, after a satisfactory 
coui'se to the period of desquamation, the troubles growing out of a 
renal complication begin. There are differences in different epidemics 
as to the liability to this complication. When it occurs a general 
oedema ensues, and dropsical accumulations form in the great cavities, 
especially in that of the peritoneum. The urine is scanty, dark from 
the presence of blood, has a high specific gravity, and is heavily loaded 
with albumin. There are present vomiting and purging, dyspnoea 
from accumulation in the cavities, headache, somnolence, fever which 
varies in type, but is usually characterized by considerable remissions, 
the pulse being very slow and irregular. These cases of scarlatinal 
dropsy are usually quite fatal, not so much directly from the kidney- 
lesion, but indirectly from the pulmonary and intestinal complications. 
In other groups of cases, the specific gravity of the urine falls very 
low, and the quantity is also very scanty, and may be suppressed even 
for several days. Very formidable symptoms of ursemic intoxication 
arise under these circumstances, including defects of vision (amblyopia, 
amaurosis, albuminuric retinitis*), coma, convulsions (partial of muscles 
of mouth and extremities, trismus, and general). During such attacks 
death may ensue from the cerebral complications, by sudden oedema of 
the lungs, by exhaustion, etc. Although the prognosis is grave under 
these circumstances, remarkable recoveries from such states are noted 
during every epidemic. When a tendency to recovery exists, the stupor 
diminishes, the convulsions cease, the stomach becomes quiet, and food 
is taken, and the urine becomes abundant. There is a great tendency to 
relapse, and the change for the worse is often due to the use of solid 
and indigestible food. Even in those cases proceeding to a favorable 
termination, the urine is found to contain albumin in small quantity, 
after apparent entire recovery. These cases usually last from one to 
two or three months before entire restoration is accomplished. Other 
cases are remarkable for the persistently high fever, the extent of the 
throat affection, the severe intestinal troubles, and the cerebral com- 
plications due not to uraemia, but to the blood-poisoning. In these 
cases, which are often fatal, the result may be due to the consequences 
of the high temperature— reaching 106°, 107°, 108°, and even 109° 
Fahr.— while the pulse is at 200° ; to the obstruction to respiration in 
the condition of the throat ; to septicaemia, cerebral haemorrhage, 
hydrocephalus, convulsions, etc. ; or to the exhaustion caused by ex- 
tensive suppuration, sloughing, and gangrene of the throat, etc. The 
duration of such cases will vary from a few days to a week, or some- 
times longer. Recurrent scarlatina is a form of the disease in which, 

* "Die Albuminurie," etc., von Dr. Hugo Magnus, Lcipsic, 1873, op. cit. 



SCAKLATIXA. 



Y87 



after the whole process is completed and convalescence established, 
there occurs an entire repetition of the first seizure, including the des. 
quamation. The second is somewhat shorter and less violent than the 
first attack. Another irregular form — to conclude the somewhat nu- 
merous varieties — is the hoemorrhagic. This is one of the most formi- 
dable varieties of the disease. The eruption is imperfectly developed, 
dark in color ; the throat is much swollen, and diphtheritic exudations 
occur, followed often by gangrene ; hjemorrhages take place from the 
mucous surfaces, from the kidneys, into the substance of internal organs, 
from the uterus, etc. These cases are uniformly fatal, death ensuing 
within the first week. Any prognostications in regard to the course 
and termination of a case of scarlatina should be guarded, for no dis- 
ease is more uncertain. The case may be regarded as manageable 
when the initial stage is not severe, the eruption appears at the proper 
time, and attains its maximum on the second or third day, the throat 
affection is not extensive, the temperature never goes above 104^^ 
Fahr., and the pulse does not exceed 140 ; the cerebral symptoms con- 
sist only of a transient delirium at the highest point of the disease ; 
the temperature regularly and uniformly declines as the desquamation 
proceeds normally, and no other symptoms arise. Certain complica- 
tions may exist without life being put in jeopardy. There may be 
mild complications of the kidney, and slight affections of the joints. 
The character of the epidemic is an important factor in the prognosis 
of individual cases. The mortality in different epidemics varies much 
— from ten to forty per cent. — and is determined largely, apart from 
the type of the epidemic, by the hygienic surroundings, and especially 
by age, infants succumbing in larger proportion than children and 
young adults. 

Treatment. — As scarlatina is a self -limited disease, and as we possess 
no specific against it, cur treatment must necessarily be symptomatic. 
In directing treatment against the symptoms as they arise, we may 
select with advantage those remedies having a power to destroy fer- 
ments. During every epidemic there are numerous mild cases, which 
require only regulation of the diet, confinement, and supervision ; for 
the mildest cases may be followed by serious complications. For the 
initial fever, tincture of aconite-root (half a drop to a drop every hour, 
according to age, in a teaspoonful of water), and, preferably, the tinc- 
ture or infusion of digitalis (from one to ten drops every two hours of 
the tincture, or five minims to a drachm of the infusion every two 
hours), are the most useful remedies. If the stomach is exceedingly 
irritable, and these remedies are rejected, a combination of carbolic acid 
and tincture of iodine is highly serviceable (B. Tinctura iodinii, 3 ij, 
acid, carbolic. 3 j. M. Sig. One half a drop to one or two drops every 
two to four hours in water). If constipation exist at the same time there 
is vomiting, the usual condition during the initial stage, the most effi- 



788 



ERUPTIVE FEVERS. 



cient laxative is calomel — from one sixth to one grain rubbed up with 
sugar and dropped on the tongue. During the period of eruption, should 
the surface be pale, the circulation feeble, and the eruption tardj in 
development, belladonna is the appropriate remedy (from two to ten 
drops of the tincture every two hours), or, if this fail, turpentine. If 
the temperature is very high during the eruption stage, and there is 
delirium, the kidneys acting freely, the wet pack is the most efficient 
remedy. If this will not be permitted, or is impracticable, the skin 
should be freely and often sponged with cold water, and rubbed with 
fat — ^lard, suet, cacao-butter, etc. In all cases when the eruption is 
abundant — is out freely — the fat should be used, the whole body in 
turn anointed every four hours. The effect of this is to allay the 
unpleasant heat and burning and to reduce the temperature. If vom- 
iting continues during this period, the remedies indicated for this con- 
dition of things during the stage of invasion are appropriate at this 
period. Should diarrhoea be present with vomiting, an excellent means 
of arresting both consists in the use of bismuth and carbolic acid 
(^. Bismuthi subnitrat. 3 j ad 3 ij, acid, carbolic, grs. ij ad grs. viij, 
mucil. acacise, aquse menth. pip., aa ? j. M. Sig. A teaspoonful every 
two to four hours). If the throat complication is at all severe, the 
best method of treating it is to apply wet compresses, cold or warm, 
to the neck, enveloping it with several folds. The throat should be 
frequently gargled, if the age permit it, with hot milk-and-water, or 
pieces of ice may be held and allowed to melt slowly, keeping them 
well back in the mouth. Caustic applications should be avoided under 
ordinary circumstances. If sloughing and gangrene are taking place, 
strong solutions of nitrate of silver, the mineral acids, solutions of car- 
bolic acid, and of permanganate of potassa, chlorate of potassa, etc., 
may be used. If there is much fetor, dilute sulphurous acid, iodine, 
and carbolic acid together, in solution, are effective, and may be freely 
applied to the fauces, and to all suppurating and sloughing surfaces. 
If there be active delirium during the eruption stage, the most appro- 
priate medicaments for the relief of this condition are bromide of po- 
tassium, chloral (if the heart's action is good), morphine, and quinine 
in combination, if there is anaemia of the brain. During desquama- 
tion, the fat inunctions should be continued. Inflammations of the 
eye and of the ear occurring at this time should receive attention. 
Kidney complications demand treatment which shall be adapted to the 
condition present. If the urine is scanty, bloody, and of high specific 
gravity, if there are pain in the back and strong pulse, leeches or cups 
should be applied to the lumbar region. Large draughts of water or 
of milk, milk and lime-water if the stomach is irritable, cream-of -tar- 
tar lemonade, infusion of digitalis, topical application to the lumbar 
region of digitalis, pilocarpine, etc., are the most appropriate remedies. 
For further particulars of the treatment of the kidney complication. 



DIAGNOSIS. 



789 



tlie reader is referred to the sections treating of these diseases. For 
those cases exhibiting profound alterations of the blood, the remedies 
possessing anti-ferment powers, as carbolic acid, salicylic, benzoate of 
soda, thymol, etc., may be employed. The most useful of these, the 
author believes, is the combination of carbolic acid and iodine, already 
mentioned. Extraordinary results have been claimed for the carbon- 
ate of ammonia, and equally confident claims have been put forward 
for yeast. The character of epidemics varies so much that caution is 
necessary in accepting the conclusions of over-confident therapeutists. 

DIAGNOSIS OP VARIOLA, VARICELLA, RUBEOLA, ROSEOLA, 
AND SCARLATINA. 

To avoid repetition, and to make the differentiation as clear as pos- 
sible, the question of the diagnosis of the above diseases has been post- 
poned until they have been considered in the regular way. They may 
be compared in their period of invasion, stage of eruption, and stage 
of desquamation. 

Stage of Invasion. — In small-pox the duration of this stage is three 
days, or until the third exacerbation of the fever ; in measles, four days 
or longer ; in scarlatina, one day or two. In measles there is a strong- 
ly marked remission at the end of the second or the beginning of the 
third day — in small-pox there is no such remission ; in measles the tem- 
perature does not decline at the appearance of the eruption — in small- 
pox there is a marked remission or an entire cessation of fever when the 
eruption appears ; in small-pox the stage of invasion is often diversified 
by rashes and there is no coryza — in measles there is coryza but there 
are no initial rashes. The invasion stage of scarlatina differs from 
small-pox in duration, in the absence of any initial rashes, in the higher 
temperature, in the coincident angina, and swelling of the lymphatics. 

Stage of Eruption. — The eruption of variola is first red spots, then 
papules, then vesicles, and finally pustules, and they appear first on 
the face, forehead, and head ; that of measles is reddish, lenticular 
spots, slightly elevated above the skin, and imparting a sense of rough- 
ness to the surface ; that of varicella, vesicles ; that of roseola, rose- 
red spots like measles, but not so prominent ; that of scarlatina, bright- 
red spots and diffused redness, with punctations of deeper red. The 
eruption of small-pox on its appearance has an indurated feel, as of a 
solid body — a bird-shot — in the skin ; that of measles imparts a sense 
of roughness wholly on the surface ; that of varicella has to the touch 
the sensation of a vesicle elevated above the surface ; and that of scar- 
latina has no roughness, but is a vivid scarlet-red spot, which disap- 
pears on pressure, to return as soon as the pressure is removed. The 
eruption of small-pox requires many days to develop, and its matura- 
tion is accompanied by distinct fever ; that of measles, roseola, vari- 



Y90 



ERUPTIYE FEVERS. 



cella, and scarlatina reaches its maximum in a day or two. The eruption 
of measles is accompanied hj coryza, watering of the eyes, a coarse, 
bronchial cough — that of scarlatina by sore-throat and swelling of the 
submaxillary and sublingual and cervical glands ; both desquamate — 
the former in fine, furfuraceous scales, often not perceptible — ^the latter 
in large flakes and very distinctly. The pustule of small-pox forms a 
distinct crust and leaves a scar ; that of varicella dries up and drops 
off without a mark. The eruption of measles differs from roseola in 
that the former is darker in color, is accompanied by fever, coryza, 
etc., not present in the latter. 

Stage of Desquamation. — Desquamation occurs in both measles and 
scarlatina, but differs greatly in thoroughness, as is above stated. The 
complications of this period are, in scarlatina, affections of the kidneys, 
dropsy, uraemia, etc. ; of measles, catarrhal pneumonia, capillary bron- 
chitis, and ileo-colitis. Desquamation does not occur in small-pox until 
the pustules have matured and crusts formed. 

ERYSIPELAS. 

Definition. — Erysii^elas is a self-limited, febrile affection, charac- 
terized by a local inflammation of the skin, terminating in desquama- 
tion, and accompanied by constitutional symptoms and the usual phe- 
nomena of blood-poisoning. 

Causes. — The most influential factor in its j)ropagation is contagion. 
It prevails in hospitals, and epidemics follow in the paths of armies. 
A peculiar poison, it is assumed, enters a wounded surface, and, after 
a certain period of incubation, the phenomena of the disease follow 
(Trousseau). Nevertheless, the disease has been divided into two 
classes — idiopathic and traumatic — the former arising spontaneously, 
the latter in connection with a wound. That this distinction must 
still be maintained is probable, because there are many cases of ery- 
sipelas for which there is no traumatic cause, and which must be, 
therefore, idiopathic. It is asserted that women are more susceptible 
to the poison than men ; but later researches have shown the incorrect- 
ness of this statement. It is a disease of all ages, but is rather more 
usual from the twentieth to the forty-fifth year of life. It occurs 
at all seasons, but is more prevalent during the variable weather of 
winter and spring. The author has witnessed two epidemics of ery- 
sipelas and puerperal fever, occurring together, and acting apparently 
in substitution. 

Pathological Anatomy. — The whole thickness of the skin is in- 
volved, and the inflammation extends through to the subcutaneous 
connective tissue. The derma is bare by exfoliation of the epidermis 
and uppermost cells and the papilla ; and the connective tissue, with 
the sweat and sebaceous glands, is (Edematous and infiltrated with 



ERYSIPELAS. 



Y91 



white blood-corpuscles in great numbers. By the accumulation of 
cells an abscess forms at the summits of the papillae. As soon as the 
redness in the skin subsides, the cells thickly distributed through the 
subcutaneous tissue undergo a granular disintegration ; a portion of 
the detritus thus produced enters the lymph -vessels, and the rest 
is absorbed, leaving the skin normal. Various changes have been 
reported as occurring in internal organs ; but little definite informa- 
tion exists in regard to them, except granular degeneration of the 
heart and vessels, the liver, kidneys, and spleen, which appears to be 
definitely established. The blood seems to be much changed, but the 
reports are not uniform as to the character of the alterations. Bas- 
tian has ascertained the existence of capillary embolisms of the cere- 
bral vessels, in some cases of death, from erysipelas of the face. 

Symptoms. — Like the other eruptive fevers, erysipelas sets in by a 
stage of invasion. The initial symptom is a chill, although not usu- 
ally a violent chill. Headache, often of an intense character, comes 
on with the fever ; and there are nausea, bilious vomiting, and entire 
loss of appetite. Before the eruption appears, and thus directing the 
diagnosis, some of the cervical lymphatics, or the submaxillary gland, 
swells — the former when the erysipelas appears on the head, and the 
latter when it attacks the face. That this sign shall be available, the 
initial stage must be longer than a half-day. A sense of heat and 
tension is felt in the skin which is about to become inflamed. A 
patch of redness appears, and af several points, which coalesce and 
thence spread widely. The red color disappears on pressure, to be 
quickly restored ; but, when the red disappears, a yellowish rather 
than white hue is seen. The skin, inflamed, is also oedematous, and it 
presents a tense, shiny appearance. The redness may commence at 
any point on the face or scalp, but it usually takes its origin from 
some accidental abrasion or from a pathological lesion, as a patch of 
eczema, or impetigo, etc. ; and, when not initiated by such cause, it is 
apt to begin at or near one of the cavities opening externally — at the 
mouth, nose, or meatus auditorius. It was the opinion of the late 
Dr. Todd that many cases of erysipelas begin in the fauces and spread 
thence to the lips and elsewhere. The appearance of the eruption is 
accompanied by a sensation of heat, burning, and tension, and some- 
times there is acute pain in the affected part. Where the parts are 
lax, and the exudation has room, there is less pain, and the swelling, 
therefore, is inversely as the pain. When there is great distention, and 
also abundant and rapid exudation, the epidermis is raised into blis- 
ters of varying size, according to the state of the skin. These blisters 
contain a transparent serum ; sometimes they are reddish from the 
presence of blood, or yellowish from the number of pus-corpuscles, and 
they contain great numbers of bacteria. Where the cellular tissue per- 
mits, the swelling may be enormous, and the head and face so trans- 



792 



ERUPTIVE FEVERS. 



formed that not a single feature is recognizable ; the eyes can not be 
opened, the nose is closed, and the lips so stiff and swollen as scarcely 
to permit of feeding. The inflammation reaches its highest point on 
the second or third day, when the retrograde process begins, and on 
the fourth, fifth, or sixth day the redness is fading and the color is 
becoming yellow, and less and less swelling is noted. The blebs dry 
into yellow scabs or crusts. Suppuration may take place at various 
points after the termination of the inflammation in the skin, but the 
pus is usually absorbed without difficulty. Desquamation of the epi- 
dermis takes place over the whole area occupied by the inflammation, 
and the hair drops out, to be, however, quickly reproduced. During 
the maximum of the inflammation the scalp is very tender, and much 
pain is experienced wherever the head rests. The great peculiarity of 
erysipelas is its migratory character, spreading widely from the point 
where it first appeared to distant parts of the body. The margin of 
the redness is not sharply defined, but the swelling forms an abrupt 
ridge. The diffusion of the inflammation is not a mere chance, but 
pursues its course along the lines of least resistance, as determined by 
the arrangement of the fibrous-tissue bundles. The opinion of Todd, 
that erysipelas may start from an inflammation of the fauces, is sup- 
ported by Trousseau and other authorities, and the erysipelas may 
extend downward into the glottis. The mucous membrane may also 
be attacked secondarily by extension of the inflammation from the skin. 
A heavily coated tongue, whitish or y-ello wish- white, becoming blackish, 
and ultimately peeling off in large flakes, is the condition of this organ. 
There are usually much nausea, protracted vomiting, entire loss of ap- 
petite, and excessive thirst. The intestinal evacuations may be nor- 
mal, or diarrhoea may be present, or black, foul-smelling, unhealthy 
discharges may occur. Ulcerations of the duodenum, and consequent- 
ly intestinal haemorrhage, are by no means uncommon. The urine may 
contain albumen and casts, and indeed a small quantity of albumen 
seems an invariable result ; hence uraemia, with all its possibilities, 
may enter into the symptomatology of erysipelas. There are few 
cases of severe erysipelas without some transient delirium. Often 
there is active delirium during the highest point in the case. There 
are three chief sources of the delirium : cerebral anaemia, a reflex re- 
sult of the cutaneous inflammation ; alcoholic excess ; thrombosis of 
the capillaries, or sinuses. The two first named may or may not be 
important ; the last is probably always fatal. Fortunately, it is rare. 
It was Bastian, we believe, who first pointed out the capillary throm- 
boses resulting from facial erysipelas. The explanation is afforded 
by the intimate anatomical connection of the facial vein with the 
pterygoid plexus and cavernous sinus. Delirium is also a result of 
continued high temperature, but more especially a result of a combina- 
tion of high fever with cerebral anaemia, the patient one who had been 



ERYSIPELAS. 



793 



addicted to alcoholic excess. At the onset of the inflammation the 
fever may reach 104° or 105° Fahr. The type of the fever is remit- 
tent, and a rapid defervescence ensues usually about the fourth, fifth, 
sixth, or seventh day ; but this defervescence is determined by the 
cessation of the inflammation in the skin. If the eruption continues 
to spread, there will be fluctuations in the temperature corresponding 
to the varying condition of the skin. The pulse varies accordingly 
and ranges from 100 to 140. 

Course, Duration, and Termination. — Erysipelas corresponds to the 
other eruptive diseases, in its tendency to spontaneous cure at a certain 
period, but this is less certain, owing to its erratic course over the skin. 
The usual duration is from one to three weeks, but it may continue 
much longer when it tends to spread over a large part of the integu- 
ment. When it ceases, in that which may be regarded as the typical 
mode, on the fourth, fifth, or sixth day, by a rapid defervescence of the 
temperature, there often occurs some critical evacuation — a profuse 
sweat, free intestinal movements of a very offensive character, or a 
large urinary evacuation ; but these critical phenomena are not always 
present. Primary or idiopathic erysipelas, notwithstanding the hor- 
rible aspect presented by the patient and the occurrence of considerable 
delirium, usually terminates in recovery. The convalesence is rather 
tedious because of the low condition to which the patient is reduced, 
even in favorable cases. There are dangers, fortunately rather rare, 
which attend the primary form of the disease — the occurrence of 
thromboses, capillary or of the sinuses ; the formation of ulcers in the 
duodenum ; the extension of the inflammation to the fauces ; and the 
depression of the powers of life, which may coincide with the sudden 
defervescence of the temperature. The traumatic form is more seri- 
ous, because the erysipelatous inflammation is added to the complica- 
tions of the injury. Furthermore the local hygienic conditions sur- 
rounding the wounded are favorable to the development of serious 
complications. Erysipelas coming on during convalescence from such 
serious diseases as typhoid, pneumonia, diseases of the heart, diabetes, 
etc., is always a very dangerous malady. On the other hand, impor- 
tant complications may arise during the course of an ordinary erysipe- 
las. Thus a pneumonia, pleuritis, peritonitis, or meningitis, may arise 
by extension of the disease. Although the connection between the 
external malady and the disease within can not always be traced, it 
probably exists. Finally, an attack of erysipelas may terminate in 
pysemia. 

Diagnosis. — Erysipelas may be confounded with erythema, urticaria, 
and with phlegmonous erysipelas. Erythema is a superficial redness 
without inflammation — without heat and swelling — is without fever, 
and does not desquamate. Urticaria occurs in the form of wheals 
that itch a good deal and disappear in a few hours. Phlegmonous 



794: 



ERUPTIVE FEVEES. 



erysipelas, so called, is a deep-seated inflammation, with suppuration, 
spreading along the connective tissue and by the intramuscular planes 
from a wound or injury, and does not take the course along the integu- 
ment as erysipelas. So characteristic are the appearance and behav- 
ior of erysipelas that it would seem impossible to mistake it for any 
other disease. The diagnosis by anticipation should not be overlooked 
— the occurrence of enlarged lymphatics in the neck in the case of ery- 
sipelas of the scalp, and of enlarged submaxillary glands in the case 
of erysipelas of the face. 

Treatment. — The perturbating treatment formerly used is now no 
longer employed. The mildest cases require only a laxative, a suit- 
able diet, and the local application of some vaseline to abate the heat 
and burning. In the more severe cases there can be no doubt of the 
value of quinine, especially if combined with belladonna. To avoid the 
complications which may arise in even simple cases, the author gives 
the tincture of belladonna, or preferably a solution of atropine (atropin^e 
sulph. gr. j, aquae ^ j- Sig. One drop every four hours in some 

water). As the effect of the atropine accumulates, the interval between 
the doses is enlarged. In the more severe cases quinine should always 
enter into the treatment, and in full medicinal not antipyretic doses 
(I^ Quininse sulph, 3ij, ext. belladonna; gr. iij. M. Ft. xpil. Sig. One 
every four hours). The delirium of anjemia, the usual form, espe- 
cially in those addicted to alcoholic excess, is best relieved by alco- 
holic stimulants, and morphine and belladonna, if the latter does not 
enter into some other combination. The systematic use of milk and 
beef-essence is necessary in all severe cases, especially under the con- 
ditions named above. Tincture of chloride of iron, in half-drachm 
doses every four hours, is much commended by the English physi- 
cians, and with good reasons. In traumatic erysipelas Mr. Higgin- 
botham's mode of applying a solution of silver nitrate in nitric ether 
is most serviceable. The surface must be carefully washed and dried. 
Then the following solution is brushed over the inflamed area, and for 
a short distance beyond on the healthy skin. On drying, should any 
part of the skin appear untouched, the solution is reapplied to these 
parts. The usual strength is about as follows : ^ Agenti nitrat. 3j, 
spts. setheris nitrosi 3 ij. M. Sig. Apply with a brush. An aqueous 
solution of two drachms to the ounce may be employed instead. The 
topical applications recommended are almost innumerable — a fact which 
indicates the uncertainty of value of any article. As a rule, irritating 
applications do more harm than good. To this dictum must be ex- 
cepted the application of nitrate of silver, in the traumatic form of the 
disease. The author has seen mnrcurial ointment, diluted ten times 
with lard, very successful. Probably still better is the following : 
Vaseline | j, acid, carbolic. 3 ss., or less, which should be brushed over 
the inflamed area three or four times a day. Above all remedies and 



TYPHOID FEYER. 



795 



applications is the use of a nutritious diet. From the very beginning 
systematic feeding should be carried on. When the patient can retain 
nothing else, lime-water and milk may be retained. But, when the 
stomach becomes quiet, milk, eggs, animal broths, etc., should be given 
at regular intervals, and, when necessary, stimulants. Trousseau {op. 
cit.) used no remedies except a laxative, but he pushed the adminis- 
tration of food, and of the great number of cases treated by him only 
three died. 



TYPHOID FEVER. 

Definition. — Typhoid fever is an acute febrile affection, self -limited, 
feebly if at all contagious, and characterized by a peculiar eruption 
on the abdomen, by a form of diarrhoea, by stupor and low delirium, 
by thickening and ulceration of Peyer's patches, by infiltration and 
softening of the associated mesenteric glands, and by swollen spleen. 
Various names have been applied to this disease. In Germany * and 
France, t and on the Continent generally, it is now called abdominal 
typhus " ; in England and this country it is usually designated typhoid 
— rarely enteric fever, the term which was originally proposed by the 
late Professor George B. Wood. Notwithstanding the term typhoid 
is excessively faulty, it is so universally used in this country that the 
author has adopted it. 

Causes. — Typhoid owes its origin to a peculiar poison, whose source 
and nature have thus far eluded investigation, but is associated with 
the decomposition of animal matter under certain conditions. It is 
never produced by mere decomposition of animal matter, faeces, or 
the contents of sewers ; it is essential to the formation of the poison 
that the typhoid germ be present, and this germ finds in these decom- 
posing animal matters a suitable soil for its growth and development. 
It does not originate de novo, but there must be present some typhoid 
matter furnishing the material for a new growth. There are sound 
reasons for concluding that the poison is contained in the excrements, 
but it seems necessary for some change to go on in them to develop 
the activity of the poison, for when in the fresh state they manifest 

* " Handbuch der Pathologie und Therapie des Fiebers," von Dr. C. Liebermeister, 
Leipsic, 1875, p. 690. 

f "Traite de Pathologie Interne," par S. Jaccoud, Paris, 1871. 



796 



FEVERS. 



no activity. Admitted to the cesspool, or to the sewer, or thrown 
on the ground, the germ becomes active and multiplies, so that the 
excretions of a single patient may develop sufficiently to poison a 
large community. The germ of typhoid is extremely viable, and 
preserves its activity for a long time, so that, should typhoid occur in 
a given locality and then disappear for a long time, another epidemic 
may develop without the introduction of a new case. How long the 
poison may remain in the body before the advent of symptoms can 
not be very definitely established. The average duration of the incu- 
bation period may be stated at three weeks, although it may be as 
short as one week, or as long as four. The vehicles by which the dis- 
ease-germs reach the body are air, water, articles of food, etc. In the 
gaseous exhalations from the sewers and privies, the materies morhi is 
carried up and is inhaled ; dissolved in drinking-water or in milk, it is 
conveyed into human stomachs, and it may be deposited on other arti- 
cles of food to be similarly disposed of. That the materies morhi does 
not infect a larger number is probably due to the insusceptibility of 
many persons receiving it. Susceptibility to the poison is developed by 
various influences. The seasons have the power to modify the preva- 
lence of the disease. In this country the fall and winter are seasons of 
the greatest prevalence of typhoid. Loomis * says it is most prevalent 
in autumn, whence it is known as " autumnal fever." The condition of 
the water-supply, as to its elevation, Buhl has shown for Munich, is an 
important element, and that typhoid decreases as the water rises, and 
increases as the water falls. Age affects the predisposition to typhoid, 
and the tendency to it is greatest from fifteen to thirty years ; it is 
almost absent in children under one year and in the aged. Men are 
rather more susceptible than women, and the disease selects by pref- 
erence the most vigorous and able-bodied, and passes by those suffering 
from chronic diseases. One attack furnishes exemption against those 
in the future, but this rule is frequently violated. Recurring typhoid, 
however, like recurring scarlatina, is not uncommon. 

Pathological Anatomy. — The lesions of typhoid fever are eminently 
distinctive. The extent of the changes, although, as a rule, indicative 
of the violence of the attack, is not always so ; for with comparatively 
few lesions there may be formidable symptoms, and vice versa. As it 
is probable that the poison enters the intestinal canal, and there begins 
its ravages, it is most appropriate to begin the sketch of the morbid 
anatomy with the intestinal lesions. The title dothienenthHe, first 
given to this disease by Bretonneau, and adopted by Trousseau,f was 
intended to emphasize the importance and particularity of the intestinal 
lesions. Conforming to the method of Trousseau and of Liebermeis- 

* " Lectures on Fevers," by Alfred L. Loomis, A. M., M. D., New York, WilUam Wood 
& Co., 1877, p. 403. 

f "Clinique Medicale," tome premier, Paris, 1865, p. 212, ct seq. 



TYPHOID FEVER. 



ter, who pursued a chronological arrangement, we may divide the ap- 
pearances into periods of weeks. In the first week there are more or 
less hypersemia and swelling of the mucous membrane in the ileum 
at its lower part, and especially around the patches of Peyer. Coinci- 
dently, a few of Peyer's glands and some solitary follicles are swollen 
by infiltration, especially those glands near to the ileo-ctecal valve, 
and by the end of the first week the infiltration has become general. 
The concyestion is not limited to the mucous membrane, but often ex- 
tends to the peritoneal surface, which is intensely hypersemic (Lyons*), 
to the mesentery, and to the spleen. In the second week occurs the 
infiltration of the glands of Peyer, and the hyperaemia lessens. Stim- 
ulated, we may suppose, by the typhoid-poison, the cellular elements 
of the glands, agminated and solitary, undergo a rapid proliferation, 
by multiplication of their nuclei and by division. This increase of 
their contents causes them to swell in all directions, so that they rise 
above the general surface of the intestine, and appear dark or reddish. 
The solitary follicles vary in size from half a line to a line in diameter, 
to the volume of a small pea, and may even reach the dimensions of a 
bean, while the patches, oval in shape, are elevated above the surface, 
from one sixteenth to one quarter of an inch. The new cells are not 
confined to the glands entirely, but wander forth, infiltrating the 
neighboring mucous membrane, and, passing through the muscular, 
penetrate to the subserous layer. At and near to the ileo-csecal valve, 
a number of the patches cohere and unite, forming oblong masses, and 
even surrounding the valve with a ring. The patches also coalesce at 
the extremity of their long axis, parallel to the long axis of the intes- 
tine, and thus attain extraordinary length. The number infiltrated is 
not always the same ; they may all be involved to a greater or less 
extent ; there may be but three or four. The same differences exist 
in respect to the number of solitary follicles infiltrated. The rapid and 
large production of new cells imparts to the glands and follicles a soft, 
spongy character, and soon leads to a necrotic softening and sloughing. 
It is, however, in the more pronounced cases that the patches become 
necrotic. They have usually a greenish color, from the presence of 
bile-pigment, or are stained a brownish color by the intestinal juices. 
The sloughs are cast off during the second week, leaving an ugly exca- 
vation which reaches to the muscular coat, and often to the serous. 
These ulcers have the shape and size of the involved patches, and are 
elliptical in form, their long diameter parallel to that of the intestine, 
and their margins are thick and sharply defined. Enormous ulcers 
may form in the neighborhood and around the valve, by the union of 
many ; indeed, this part may be a mass of ulcerations, with small bits 
of mucous membrane between them. The process of ulceration and 



* " Treatise on Fever," Philadelphia, 1861, p. 362. 



798 



FEVERS. 



necrotic sloughing may be postponed to a much later period. Several 
months, indeed, may be occupied in the process of typhoid infiltration, 
without ulceration taking place (Lyons). But such examples are clearly 
exceptional. When extrusion has taken place, the process of healing 
goes on in favorable cases. The floor of the ulcer is soon covered with 
granulations, and, a gradual contraction taking place, the ulcer is ulti- 
mately closed, a cicatrix marking the site. A restoration to the nor- 
mal is accomplished in many patches and follicles without ulceration. 
The new cells disintegrate and disappear, the hypereemia subsides, and 
the original state is resumed. It is probable that this is the course of 
the lesions in the mildest cases. The two processes are usually mixed. 
Amid more or less extensive sloughing and destruction of substance, 
there Avill be seen patches and follicles that do not ulcerate, and whose 
new elements degenerate and are absorbed. The part of the intestine 
affected has an influence on the result — the sloughing and ulceration 
taking place below, and the retrogression by degeneration and absorp- 
tion occurring above. The process of sloughing and repair may go 
on together, and at a very advanced period, so that perforation may 
result when healing is far advanced. 

It has already been mentioned that the initial hypergemia involved 
the mesentery as well as the intestines. Other changes occur in the 
mesentery, following in the wake of those going on in the intestine. 
The glands swell, are congested, reddish, and succulent. They enlarge 
very considerably by an accumulation of their contents, and attain the 
size of a bean, an almond, or a pigeon's-egg. They presently soften, 
and many become diffluent and are barely retained within the capsule. 
When retrogression takes place the soft material is absorbed, the con- 
gestion disappears, and the glands shrink to their normal size. Some- 
times a purulent collection remains behind, and a slow, cheesy trans- 
formation is effected. It not unfrequently happens that other lym- 
phatic glands are infiltrated to some extent, such as the retroperito- 
neal and bronchial glands, etc., but in the mesentery the glands usually 
attacked are those immediately related to the diseased part of the in- 
testine, although in severe cases all may be swollen and infiltrated. 
The spleen is affected in a similar manner. When the hypergemia be- 
gins in the intestines the spleen enlarges, and by the end of the first 
week the enlargement is sufficient to be recognized through the abdom- 
inal wall, and at the maximum the organ is two or three times larger 
than normal. The change consists in a multiplication of the cellular 
elements, which at first increases the firmness of the organ, but ulti- 
mately it becomes exceedingly soft, so that it almost falls to pieces by 
its weight. The retrogression occurring in the spleen consists of a 
degeneration and disappearance of the new elements ; the capsule con- 
tracts, the trabeculse become more firm, and the pulp more compact. 
The lesions thus far considered are peculiar to typhoid. We have 



TYPHOID FEYER. 



799 



nov to discuss changes due to a persistent elevation of the tempera- 
ture, and known under the designation of parenchymatous degenera- 
tion of organs — the liver, kidneys, muscular tissue of the heart, the 
nervous system, and muscular system of animal life in general. Par- 
enchymatous degeneration is a granular and fatty change affecting 
the proper gland elements. In the liver the cells become clouded 
with fat-granules and the nuclei disappear, and when the change is 
most advanced they break down into granular fragments. The effect 
of this process is to diminish the firmness and consistency of the organ, 
to change its color to a grayish or yellowish-red, and to materially 
diminish the blood in the small vessels. The degree of the change 
varies chiefly in accordance with the range of temperature ; it may be 
very slight or very considerable, and the right lobe is usually further 
advanced in the change than the left. In the kidneys the epithelium 
of the tubes, first of the cortex, then of the pyramids, becomes gran- 
ular, cloudy, and the contour indistinct, the nuclei disappearing, and 
at last breaks down into granular fragments. The effect of these lesions 
is to diminish the firmness of the organs, and to change their color. 
In the kidney, as in the liver, the amount of the change varies, and is 
determined by the range of temperature. Albuminuria results when 
the alteration is at all extensive. Yery important are the changes 
occurring in the cardiac muscle. The granules appear in large num- 
bers, arranged in parallel rows, filling the fibers, and ultimately caus- 
ing a disappearance of the striae. The result of this change is very 
injurious. The tissue of the heart is soft, flabby, and easily torn, and 
the organ in advanced cases can not maintain its shape when laid on a 
table, but flattens out like so much mush. In the muscles the degen- 
eration takes the two forms of granular and waxy. In the brain the 
changes due to parenchymatous degeneration have not been, as yet, 
adequately studied, but the naked-eye alterations are very definite, 
the chief change consisting in anjemia, oedema of the brain, the sub- 
arachnoid spaces, the perivascular lymph-spaces, and the ventricles 
containing a good deal of fluid. Some parts of the brain are less firm 
than normal, and more or less atrophy occurs, the convolutions flatten- 
ing and the ventricles enlarging, etc. Rarely the lesions of an acute 
meningitis are superadded to those of typhoid. In the respiratory 
organs there are various lesions, which, if not essential to typhoid, are 
at least usually associated with those that are peculiar. Not unfre- 
quently the larynx is attacked with ulceration ; but the most charac- 
teristic change is that of catarrh of the bronchial mucous membrane, 
which is swollen, deeply injected, and coated with viscid mucus. The 
access of air being cut off from some of the vesicles, they collapse, or 
pass into the state of atelectasis. The dependent portions of the lungs 
are in the condition of hypostasis, with or without oedema, and in rare 
cases lobar or lobular pneumonia. 



800 



FEVERS. 



Symptoms. — As a rule, a prodromic period usliers in a case of 
typhoid. For a week or ten days, or even longer, a lack of the usual 
vigor and a disposition to tire easily are perceived. Headache, epis- 
taxis, tinnitus aurium, a poor appetite, and a slight diarrhoea, are also 
noted. The mind is dull, and mental application is very fatiguing ; 
sleep is disturbed by dreams and is unrefreshing. Presently some 
chilliness is felt at different times and for several days, and the fever 
begins ; the strength is exhausted, and the patient betakes himself to 
bed. In other cases, the prodromic period is characterized by the 
development of an acute catarrh of the stomach ; there are disgust 
for food, nausea, and a heavily coated tongue ; temporary relief is 
afforded by spontaneous or contrived vomiting, but the symptoms are 
soon resumed, the nausea continues, some diarrhoea occurs, great weak- 
ness is felt, headache, hebetude of mind, and disturbed sleep are ex- 
perienced, and gradually the fever lights up. In still other cases— and 
they are relatively very numerous in the malarial regions of this coun- 
try — an attack, apparently of intermittent fever, precedes the fever 
proper ; there may be several distinct paroxysms, but the fever soon 
assumes the remittent type, and the phenomena of typhoid gradually 
develop, A few cases begin without any prodromes. A person, ap- 
parently in full health, is unexpectedly seized with some chilliness, 
followed by fever, languor, headache, etc. On the next day there is 
more chilliness, the fever is more pronounced, the mind is already be- 
coming dull, and the other symptoms of typhoid come on immediately. 
The disease is held to originate with the first chilliness or the first 
elevation of temperature, and from these data is computed the dura- 
tion of the different periods. As the appearance of fever marks the 
onset of the disease, so its decline and disappearance establish con- 
valescence. 

First Week. — The symptoms of the prodromic period are more 
pronounced : there are violent headache, a sense of confusion and 
mental weakness ; singing and drumming in the ears ; some bleeding 
at the nose, often but a few drops escaping ; the eyes are intolerant 
of light, the ears of sound ; the patient may still get on and off the 
bed, but, when he attempts to stand erect, his limbs tremble, and he is 
seized with vertigo. The appetite is gone and the suggestion of food 
is repugnant ; there is a bad taste in the mouth, and the thirst is ex- 
cessive. The tongue is at first large, pale, indented at the margins 
with the teeth, but it becomes dry and smaller by the fifth day ; the 
coating peels off with the epithelium in patches, leaving a very red, 
dry, and glazed surface, and it is also somewhat tremulous. Some 
diarrhoea may have existed during the prodromic period, and there is 
often a tendency to constipation during the first week, but, when this 
is the case, it is found that a light purgative acts with unwonted vio- 
lence. More or less diarrhoea exists during the first week. At firsi; 



TYPHOID FEYER. 



801 



the stools consist of thin, brownish faeces, having a rather strong odor, 
but they increase daily in number and change in character toward the 
end of the second week, when they assume the yellow ochre color, the 
well - known " pea-soup " appearance. When they are permitted to 
stand, they separate into two distinct strata : the upper one liquid, 
holding salts, extractives containing bile, epithelium, ammoniaco-raag- 
nesian phosphate, and fat, finely emulsionized ; the lower one, more 
consistent, containing analogous ingredients to those in the upper 
layer, but, in addition, a quantity of soft, yellow concretions made up 
of fat, albumin, pigments, and phosphates (Jaccoud). Great interest 
attaches to the microscopic examination of the stools, since it is 
generally conceded that the typhoid matter exists in the stools, but 
the results thus far attained can not be regarded as conclusive, al- 
though various microbes have been described by Klebs * and others 
as the specific infective element, or typhoid germ, but until their in- 
fective power is demonstrated their relation to typhoid fever must 
continue conjectural. Gurgling in the right ileo-csecal region has 
been classed among the symptoms of this period, but, as it is pres- 
ent in diarrhceal affections, there is no great value to be attached 
to it alone. Tenderness, as well as gurgling, makes a more signifi- 
cant impression, especially if, as there ought to be, at the end of the 
first week, some fullness, even distention of the abdomen. At this 
time distinct increase in the area of splenic dullness can be made out, 
and the enlarged spleen may be often felt. Enlargement of the tonsils, 
follicles of the pharynx, and of the large follicles at the base of the 
tongue takes place coincidently with the development of the intestinal 
glandular appendages. Catarrh of the bronchial tubes, shown by some 
dry and moist rales over the dependent portions of the lungs especially, 
comes on at this time, but its intensity varies in different epidemics 
and in different individuals. At the end of the first, or at the beginning 
of the second week, appear the very characteristic disorders of the ner- 
vous system. The restlessness, the complaints about the aching in the 
back and limbs cease, and instead there is a condition of apathy and in- 
difference. The patient becomes somnolent, but is easily aroused, and 
does not sleep w^ell at night. Some of his indifference and stupidity of 
expression is due to dullness of hearing, and hence he must be spoken 
to somewhat loudly. When roused he responds correctly, and expresses 
himself as feeling very well. From the seventh to the tenth day some 
disturbance of mind is noted ; it may be toward evening, or at night 
only, or when roused, and ordinarily it is nothing more than a tranquil 
muttering, or, as it is commonly expressed, " low-muttering delirium." 
Sometimes the delirium takes a more active character : it is wild, furious 

* For an account of the more recent discovery of Klebs, see " Der Ileotyphus eine 
Schistomycose," " Archiv fiir experimentelle Pathologie und Pharmacologic." Zwolften 
Bandes, s. 231. He gives the results of examination of twenty-four cases. 
53 



802 



FEYERS. 



and ungovernable ; the patient gets out of bed, resists the attempts to 
feed him, spits his drink or medicine into the face of his nurse ; will 
not keep any covering on him, talks incessantly, and not only gets out 
of bed, but will jump out of the window. This condition of wild 
delirium coincides with greatly elevated temperature, rapid pulse, and 
the other evidences of extreme illness. Fortunately, these cases are 
rare. Usually the delirium is a low monotone, mumbling incoherent- 
ly, and is accompanied by picking at imaginary objects on the bed- 
clothes, and subsultus tendinum. The trembling of the muscles is 
seen not only in the subsultus of the tendons of the forearms, but in 
the protrusion of the tongue. If not too far gone in stupor, the pa- 
tient may yet protrude his tongue when urged to do so, but he does it 
slowly, hesitatingly, with much trembling, and he forgets to return it 
again, keeping it protruded until forced to return it. The urine is 
acid in reaction, is rich in urea, urates and extractives, and poor in 
chlorides. The urine frequently contains the urinary indigo, leucin 
and tyrosin, and in many cases albumen. At the end of the first 
week, or at the beginning of the second week, an eruption of roseola 
appears, in the form of small, isolated, lenticular spots, about the size 
of a pin's-head, disappearing on pressure, to quickly reappear when the 
pressure is removed. They vary greatly in number, often from five 
to twenty, scattered over the lower thorax and abdomen. They may 
be much more numerous, several hundred in number, and may be dis- 
tributed generally over the body. They may be, and indeed often 
are, entirely absent, especially in the milder cases. It occasionally 
happens that a larger, darker eruption, of a pigmentary character, 
appears before or with the roseola, but these have no special impor- 
tance. When there has been much sweating, an abundant crop of 
miliary vesicles known as " sudamina " may appear on the neck, chest, 
and elsewhere. With the close of the second and the beginning of 
the third week, the typhoid symptoms develop in intensity. The 
stupor increases, so that the patient can hardly be roused, and is indif- 
ferent to all about him. If liquids are placed in the mouth, they are 
slowly swallowed. The patient lies on his back, his eyes partly closed, 
mouth open and black with accumulated sordes, his face is sunken, 
dusky, with a faint, reddish tinge in the center, the lips, now and then 
moving with an unintelligible muttering, are dry and cracked, and his 
strength is so far exhausted that he can not keep his position, but sinks 
toward the foot of the bed. The faeces and urine may be passed invol- 
untarily, or the urine may be retained and dribble away, the bladder 
becoming enormously distended. The pulse continues frequent, from 
90 to 120, or higher, but its force declines. The impulse of the heart 
is feeble, and hence a tendency to stasis in the lungs and brain ex- 
ists. The pulse is compressible, and its tension so low that it has a 
double beat (dicrotic pulse). The fever of typhoid, although called con- 



I 



TYPHOID FEVER. 



803 



tinuous, is not so ; it has a distinctly 




Fig. 53.— Temperature in Typhoid Fever. 



remittent type. For the first 
week there is a gradual as- 
cension, and, although there 
is a morning remission and 
an evening exacerbation, each 
exacerbation is a little higher 
than the preceding, until the 
maximum is reached. During 
the second week the fever is 
continuous ; during the third 
it begins to be remittent, and, 
during the fourth, intermittent, 
the daily exacerbations lessen- 
ing regularly until the normal 
is reached. The fever at its 
maximum is continuous, be- 
cause the daily remissions cor- 
respond to the morning and 
evening variations of the daily 
temperature in health. With 
the remissions at the end of 
the third week, there are evi- 
dences of a change for the bet- 
ter in favorable cases. Dur- 
ing the third week, however, 
chiefly occur the complications 
which exercise so unfavorable 
an influence over the progress 
of the disease, but these are re- 
served for separate considera- 
tion. In the fourth week the 
patient is well aroused from 
the stupor, and is fully con- 
scious of his condition. In- 
stead of indifference, he is full 
of complaints. His eye is 
brighter, and the face, though 
emaciated, begins to have ex- 
pression again. The delirium 
ceases, the nights are less dis- 
turbed, and, instead of somno- 
lence, the sleep although re- 
freshing is interspersed with 
periods of wakefulness. The 
tongue and gums clean, the 



804 



FEVERS. 



appetite returns ; the diarrhoea ceases, and is replaced by constipation ; 
the flatulent distention of the abdomen subsides ; the spleen shrinks ; 
the urine becomes more abundant and limpid, and there are copious 
perspirations for several days, occurring especially during sleep. 

Course, Duration, and Termination. — The course of the fever as 
described is the usual one of a perfectly developed case. But there 
are many variations due to individual peculiarities, to surrounding in- 
fluences, to complications which may be most conveniently studied 
under this head. The principal cause of a fatal termination is the 
prolonged high temperature, and hence, in any prognostic estimate, 
this must be considered. Thus Liebermeister shows that, when the 
temperature was under 104° Fahr., the percentage of mortality was 
9*6 ; if the temperature reached and passed 104", the mortality was 
29 '1 ; if the temperature rose to 105 •8'' or over, the mortality was 
greater than one half. Next to the height is the duration of the 
fever ; and, consequently, the longer the maximum of the fever is 
maintained, the greater the mortality. The point to which the fever 
attains at the end of the first week, as a rule, indicates the range of 
temperature to occur, for in uncomplicated cases it is then at the 
maximum. Furthermore, the greater the daily fluctuations of the 
fever, the less severe it will prove. Treatment has exercised great in- 
fluence on the mortality, especially treatment based on a recognition 
of the importance of reducing the temperature. Age has a great in- 
fluence over the termination of typhoid — in the young the mortality 
is proportionally less ; in the aged proportionally greater. The indi- 
vidual constitution has an undoubted effect in increasing or diminish- 
ing the mortality ; the nervous and excitable bear the disease poorly, 
and the phlegmatic better ; the lean and muscular also endure the 
strain of the disease better than the fat. But the habitual indulgence 
in spirits has a more unfavorable influence than any of the conditions 
named. In every epidemic there are many cases of much milder type, 
and there are also irregular and abortive forms. In the milder cases, 
the temperature rarely exceeds 103° in the axilla ; there is no delirium, 
only confusion of mind on awaking from sleep, and hebetude of mind ; 
the diarrhoea is slight, and the different periods are short, so that the 
whole duration may be comprehended in twenty-one days. Those are 
regarded as abortive in which there are no prodromes, the symptoms 
begin abruptly, often with a distinct rigor, the temperature rising in a 
day or two to the maximum of 104° Fahr., and, without the weeks of 
continued fever, assuming the remittent and intermittent form of the 
fourth week at the end of the first, and terminating within two weeks. 
While the mild form is extremely common in this country, the abor- 
tive forms, according to the author's observation, are infrequent. 
The course, duration, and termination of typhoid are much influenced 
by the complications. Haemorrhage of the intestines is one of the 



TYPHOID FEVER. 



805 



most important. This takes place at various times in the course of 
the fever, and the quantity of blood lost is very different in different 
cases. The blood may be pure, partly fluid and coagulated, or black- 
ish, or converted into a tar-like mass. The second week is the most 
usual period for the hcemorrhage ; next, the third week ; but it may 
occur at any period. The proportion of cases of haemorrhage to the 
whole number is about five per cent. When it occurs during the first 
week, it is a result of the increased pressure in the intestinal vessels — 
a necessary product of hypersemia ; if it occur in the second and third 
weeks, it is caused by the sloughs, a vessel being laid open by their 
defachment ; if later, vessels are eroded by the spread of ulceration. 
Any considerable haemorrhage, if no part escape externally, is an- 
nounced by sudden depression, coldness of the surface, pallor, faint- 
ness, weakness of the pulse, lowering of the temperature. Unless re- 
peated, the effect of the haemorrhage subsides in a day or two, the 
pulse rises, the delirium and stupor, which may have been lessened by 
it, assume their former characteristics. The more severe the haemor- 
rhage, the more injurious. The notion has been entertained by some 
that a considerable haemorrhage might have a favorable influence over 
the progress of a case, but the statistics are opposed to such an opin- 
ion, those of Liebermeister, for example, showing that the mortality 
is three times greater in those having this complication, but statis- 
tics on this point are not altogether conclusive, since usually those 
are the most severe cases, in other respects, in which haemorrhage oc- 
curs. The introduction of hydrotherapy has in Germany diminished 
the frequency of intestinal haemorrhage as a complication of typhoid. 

Perforation^ as a cause of death, occurs in from five to fifteen per 
cent. The period is from the third to the fifth week, although it may 
occur as early as the first, and is due to the extension of ulceration, the 
opening in the peritoneum being made at last by some hardened faeces, 
undigested food, sudden distention of the bowel by gas, and, it may 
be, by ascarides, which are often found in the peritoneal cavity after- 
ward. The shape of the ulcer is an inverted cone, the opening in the 
oeritoneum, the apex, having the size of a pin-head to a small pea. 
The ilium is the part usually perforated, but the ulcer may be situated 
high up in the small intestine, or it may be in the colon, especially the 
appendix vermiformis. Very often it is the ulcer of a solitary gland. 
Although the more extensive the ulcerations the greater the danger 
of perforation, yet it has happened that a single ulcer has opened the 
peritoneum. The immediate result of the perforation is shock. The 
surface grows cold, the temperature falls several degrees, the pulse 
becomes excessively feeble, and death may ensue in a condition of 
extreme exhaustion. Usually, however, the patient rallies, reaction 
ensues, and acute peritonitis rapidily develops. It sometimes happens, 
when the rupture may be produced by accumulation of gas, that the 



806 



FEVERS. 



abdominal cavity is greatly distended by it, the epigastrium rendered 
prominent, and the diaphragm pushed up, impeding respiration. At 
the moment rupture takes place, intense pain is experienced, beginning 
in the right inguinal region, and radiating thence over the abdomen. 
The temperature rises again, after some preliminary chills, and the 
phenomena of peritonitis are added to the ordinary symptoms. Re- 
covery very rarely takes place, and death occurs usually within four 
days after the perforation, unless, indeed, the first shock of the acci- 
dent paralyzes the heart. In a few cases, with profound coma, per- 
foration has occurred without causing any objective evidences of the 
complication. Perforation is much more apt to occur in men than 'in 
women. Peritonitis may be due to other causes than perforation — ^by 
the extension of ulceration to the peritoneum, by rupture of the gall- 
bladder, rupture of the spleen, etc. The author has met with a fatal 
case of rupture of the spleen, occurring during convalescence, and 
caused by a not violent bloAv on the side. Examination of the splenic 
region should be made with care after the second week, because of the 
ease with which the spleen may be ruptured. The chief complication 
on the part of the circulatory organs is granular degeneration of the 
heart-muscle already described, thromboses from cardiac weakness, 
forming in the heart or in the great vessels. In the respiratory system 
there are various changes, some of them of great importance. EjDistaxis 
and bronchitis have been already mentioned as symptoms of the dis- 
ease proper, so constant are they in appearing. Diphtheritic exudations 
in the fauces and ulcers of the larynx, due to diphtheritic infiltration 
of the mucous membrane, are occasional and very important complica- 
tions. Death is sometimes unexpectedly due to oedema of the glottis, 
and this may be produced by a laryngeal ulcer. Atelectasis, hypostatic 
congestion, splenization, haemorrhagic infarctions, and oedema, are all 
complications arising in the lungs from feebleness of the heart's action. 
Caseous pneumonia, pleurisy, and acute miliary tuberculosis are se- 
quelae, sometimes the outcome of the above-mentioned diseases due to 
stasis. Oedema of the brain is a frequent condition, which seems a 
necessary part of the morbid anatomy of typhoid. Besides this, there 
are various complications growing out of the changed state of the sol- 
ids and fluids. Cerebral haemorrhage and acute meningitis are very 
rare. Derangements of the mental faculties are by no means uncom- 
mon, and are due to the anaemia and the functional torpor of the gray 
matter. The derangement may assume the form of exaltation, or of 
depression and melancholy. When an hereditary tendency exists, the 
case assumes a higher degree of importance, those due merely to the 
condition of the brain, the result of the typhoid disease, recovering 
with less or greater promptitude. The condition of the kidneys which 
occurs in many cases, represented objectively by a trace of albumen 
in the urine, passes into well-developed Bright's disease in a small pro- 
portion of them. These go through the usual course, and terminate 



TYPHOID FEYER. 



807 



in recovery. Hseniorrliagic infarction occurs in a few cases. The 
menses frequently appear during the course of typhoid, and exercise a 
rather favorable influence over the course of the disease. Abortion is 
apt to occur, and of course adds to the gravity of the situation. On 
the part of the skin, the most important complication is that of hed- 
sores. The parts subjected to pressure are those which slough — the 
sacrum, nates, great trochanters, and the crest of the ilium. In some 
subjects, so depraved is the condition of the solids, that any part sub- 
jected to pressure sloughs. The depth and extent of the sloughing 
vary from redness, inflammation, and abrasion of the skin, to destruc- 
tion of the skin, fascia, and muscles, extending to the periosteum. The 
effect of this complication depends on the extent of the injury done. 
When there is considerable sloughing, suppuration, and decomposition, 
fever will be excited, and systemic infection, septicaemia, and pyae- 
mia result. Falling out of the hair and arrest of the growth of the 
nails are usual complications. 

Helcqyses. — Increased fever, due to some complication, may be con- 
founded with a genuine relapse, but the latter pursues the ordinary 
course of the fever, except that it is more rapid in its course and 
shorter in its duration. There occurs in the relapse a similar range of 
temperature, the spleen enlarges, roseola appears, and the other symp- 
toms in their order come on. Of itself the relapse is milder, but the 
subject enduring it is enfeebled by an illness, so that the danger must 
be regarded as greater. The number of cases undergoing relapse 
varies from six to twelve per cent. 

Treatment. — Although for typhoid, a specific disease, we have no 
specific remedy, a treatment has originated in Germany which is 
known as the specific treatment. Mercury and iodine are the specific 
remedies. There is no doubt, if statistics may be depended on, that 
calomel, in large doses during the first week, favorably modifies the 
disease. Ten grains in a single dose, on alternate days, is about the 
average of the quantity given by various therapeutists. If the tem- 
perature is high, it may be given on successive days, but the danger 
of inducing salivation is great, when it is administered at short inter- 
vals. The effect of the mercurial treatment is to lower the tempera- 
ture, to diminish the severity, and apparently lessen the duration of 
the case. The treatment by iodine consists in the administration of 
Lugol's solution — from three to five minims in water three times a 
day, and continued during the first two weeks certainly, and probably 
up to the beginning of convalescence. Taking the figures of Lieber- 
meister for illustration, they show that while the mortality under 
ordinary treatment reached 13*2, under calomel it was 8*8, and under 
iodine 10*9. The author's experience is, that the administration of 
iodine has a favorable effect on the course of the disease. He has 
used, with apparently decided success, the combination of iodine and 
carbolic acid (]^ Tinct. iodinii 3 ij, acid, carbolic. 3 j. M. Sig. 



808 



FEVERS. 



One to three drops three times a day). Nitrate of silver, sulphate of 
copper, arsenic, and turpentine, each has an advocate of its usefulness 
— all being directed against the intestinal complication or lesion. As, 
however, the main point in the management of typhoid is to keep the 
temperature within safe limits, the treatment directed to that end is 
the most important. The antipyretics available for this purpose are 
hydrotherapy, quinine, antipyrin, the salicylates, benzoates, etc. The 
method of hydrotherapy consists in immersion in water at a certain 
temperature, the wet pack, and local abstraction of heat by special 
appliances. As private houses are unprovided with the means of ad- 
ministering baths to fever-patients, this method can be utilized only 
in hospitals. The method of gradual reduction of heat we hold to be 
preferable. The patient is put in the water at 98°, and then by the 
addition of cold water the temperature of the bath is brought down to 
60° Fahr. The thermometer must be constantly' in position to observe 
the effect, and the duration of the bath ought not to exceed ten to 
fifteen minutes. The temperature requiring the bath is any consider- 
able elevation above 103° Fahr. (axillary), and the repetition of it is 
determined by the effect — every two to every six hours, night as well 
as day, may be regarded as usual. If the patient is made faint or 
depressed, some stimulant should be given before, during, or subse- 
quent to the bath, according to the result. If the bath is impractica- 
ble, the wet pack may be used with equal effect. The bed is protected 
by a gum cloth ; a sheet is wrung out of cold water ; the patient is 
thoroughly wrapped in it, and then covered up with blankets for a 
few minutes, when the process is renewed if necessary. The same 
rules hold good with regard to the repetition and management of the 
pack as of the bath, and the results achieved are equally beneficial. 
The temperature of the body may also be reduced by ice-bags applied 
to the abdomen, and by ice-water injections in the rectum, but these 
latter can not be utilized in typhoid. There are several contra-indica- 
tions to the use of cold baths. The first and most important is haemor- 
rhage from the intestines, the next is great weakness of the heart's 
action, and the third is coldness of the surface with high internal heat. 
Next to hydrotherapy, and probably superior as a remedy for reducing 
abnormal temperature of the body, is quinine. Notwithstanding the 
good results which have been obtained from baths, it is probable that 
quinine will always be preferred by many, because of the readiness 
with which it may be brought to bear on the production of heat. In- 
deed, Liebermeister, a strong advocate for hydrotherapy, says, if he 
" were forced to the unpleasant alternative of adopting only one or the 
other of these two means — cold water or quinine — I should, in the ma- 
jority of cases, choose the latter." To reduce the abnormal tempera- 
ture, antipyretic doses are required, from twenty to forty grains. A 
decline of several degrees, and lasting a number of hours, will be 
caused by a sufficient dose, and a less effect than this will not justify 



TYPHOID FEVER. 



809 



the employment of the remedy. It is a good plan to prescribe a scru- 
ple every four hours, until a decided reduction of temperature takes 
place, then its use should be suspended until the temperature begins 
to rise again. 

After extended observation of the practical results of the antipy- 
retic method, as carried out by the administration of the remedies be- 
longing to this group, the author has come to the following conclu- 
sions : If the temperature at the maximum of the daily curve does not 
exceed 103° Fahr., it is better not to interfere by an attempt to lower 
the body-heat. If the temperature persistently rises above this point, 
antipyretics least perturbating should be administered at the period 
of remission, and in sufficient quantity to make the necessary impres- 
sion, when they should be discontinued until an exacerbation is threat- 
ened. Antipyrin, disturbing least the digestive organs, should be pre- 
ferred after quinine, or to quinine if this remedy fail to have the de- 
sired effect. It is not good practice to give quinine in so-called tonic 
doses (two to four grains) for the following reasons : It disorders the 
stomach ; it increases the headache and the gloom, the hebetude of 
mind and the muttering delirium, and thus contributes to the wake- 
fulness. There is no benefit derived from it to compensate for these 
considerable disadvantages. 

If, in the treatment of typhoid, the temperature be prevented ris- 
ing beyond safe limits, there will be less and less need for attention 
to complications. Nevertheless, we must be prepared to obviate the 
tendency to death, and to correct complications. Failure of the heart 
requires stimulants, but otherwise stimulants should not be given in 
typhoid, except in the case of those addicted to their use, who require 
a regulated daily amount. Restlessness and prolonged wakefulness 
are as a rule most successfully relieved by morphine and belladonna. 
Chloral must be used with caution, because of the weakness of the heart- 
muscle. If the tongue is dry, if there is great thirst, and the abdomen 
is much distended with gas, turpentine is highly useful. Muriatic acid 
also acts well under the same circumstances. If the bowels act too 
freely, nitrate of silver, with a little opium. Fowler's solution and lau- 
danum, bismuth and carbolic acid, especially the last-named combina- 
tion, will check them sufficiently. Two or three stools a day are not in- 
terfered with, unless copious and exhausting. Careful alimentation best 
regulates the bowels. If haamorrhage occur, intestinal movements must 
be suspended by opium, the flow of blood controlled by ergotin hypo- 
dermatically and ice to the abdomen. Tannin, alum, and solution of 
chloride of iron may be prescribed internally. If perforation occur, 
opium, especially morphine, hypodermatically, is our one remedy. Stim- 
ulants may be given cautiously, and absolute rest should be maintained. 
Bed-sores are best managed by cold-water bags and the removal of press- 
ure. Before the skin breaks, it should be frequently washed with alco- 
hol and Goulard's extract to harden it. The best dressing for a bed-sore 



810 



FEVERS. 



is a mixture of equal parts of copaiba and castor-oil. A large yeast- 
poultice is an excellent application, especially when more or less weight 
is still borne by the sore surface. The alimentary treatment of ty- 
phoid fever is very important. The principal lesions being in the 
intestinal canal, the diet must be arranged accordingly. Dr. George 
Johnson has shown us that many cases of typhoid need nothing more 
than rest in bed and milk diet ; and Sir William J^ner has pointed out 
how useful milk is, and how injudiciously it is given in many cases. 
We learn from these able physicians, that milk is peculiarly adapted 
to serve as the food for typhoid-fever patients, but that it must be 
given in moderate quantity, and at suitable intervals. Milk should be 
administered about every three hours, and from two to four ounces at 
one time. Or milk may be given in alternation with a little weak mut- 
ton, beef, or chicken broth. If milk is not borne well, it may be diluted 
with barley-water. A little of Scheffer's pepsin solution and muriatic 
acid ought to be administered immediately after the aliment, if it is 
rejected by vgmiting or passes by stool unchanged. Beef -essence, as 
usually prepared and given to typhoid-fever patients, is very difficult 
of digestion, acts as a laxative, and may be seen in the evacuations 
precisely in the state in which it was swallowed. As the adynamia 
increases, egg-nogg, fortified by whisky or brandy, comes to be a most 
useful aliment, of which the patient may partake freely, but at regular 
intervals. Sufficient time ought to be allowed for the aliment given at 
one time to be digested, before another supply is turned into the stom- 
ach. A moderate quantity of a light wine should be allowed during 
the first two weeks, and whisky and brandy given in egg-nogg or 
milk-punch the third and fourth weeks. Half an ounce to an ounce of 
wine and a half -ounce of whisky or brandy need rarely be exceeded at 
one time, nor more frequently than once in three hours, unless there be 
a special requirement. Mild cases need no stimulant. The dejections 
of a typhoid patient should be at once disinfected by a strong solution 
of sulphate of iron or chloride of zinc. The patient's bed should be 
free from all unnecessary appendages, and be placed in the middle of 
the apartment. Air should be freely admitted. But one person should, 
as a rule, be permitted in the apartment at a time, and the patient's 
attention should not be attracted to persons and things about him. 



TYPHO-MALARIAL FEVER. 

History. — This term was invented by the late Dr. Woodward, of 
the Army, to express his conception of a hybrid formed by a combina- 
tion of typhoid fever and malarial fever. As it was used in the medi- 
cal reports of the army, and hence at once adopted by a large propor- 
tion of the physicians of the United States, it came to be regarded as 
signifying a new disease. This unfortunate misconception was fur- 
ther promoted by Dr. Woodward's published utterances on the sub' 



TYPHO-MALARIAL FEVER. 



811 



ject. In his work on " Camp Diseases " we find bim declaring that 
typho-malarial fever is a substantive malady, tbat bas a special mor- 
bid anatomy. He found, as be alleged, anatomical changes belonging 
to and characteristic of the new disease. The author of this work was 
the only one to oppose these doctrines and Dr. Woodward's typho- 
malarial fever becoming a fixture in the nomenclature of diseases. 
The author maintained that Dr. Woodward had committed an error 
of observation, that the morbid anatomy of typhoid was in nowise 
altered by an existing malarial complication, and that, symptomatic- 
ally, remittent fever running into a typhoid state was mistaken for 
true typhoid. The author further maintained that, admitting the ex- 
istence of a malarial complication, this no more constituted a reason 
for constructing a new disease than the presence of such other com- 
plications as scurvy, crowd-poisoning, rendered the manufacture of 
new terms necessary to express these relationships. Dr. Woodward, 
after ten years' silence, at last, in a paper read before the Interna- 
tional Medical Congress at Philadelphia, retracted his former state- 
ments, and admitted that the morbid anatomy of typhoid fever re- 
mained unaltered by any malarial complication. Consequently, his as- 
sumption of a typho-malarial fever fell unsupported. Unfortunately, 
an error of this kind is more easily established than it is destroyed by 
subsequent refutation. The reviewers of this work, who have only 
seen that the author did not admit the existence of a typho-malarial 
fever, and criticised the omission in an unfavorable tone, seem to be 
totally ignorant of the fact that the author of the term admitted its 
inapplicability and the error of his observations. 

Clinical Aspects of Malarial Typhoid. — Although typhoid fever con- 
tinues to be typhoid, practical physicians have long known that, when 
the typhoid germ develops in an organism saturated with the malarial 
poison, the clinical features of the fever are somewhat modified ; but 
the modification consists in the increased excursions of the daily tem- 
perature. Influenced in their conception of typhoid as a continued 
fever by this term, physicians have too often overlooked the fact that 
the thermal line of typhoid is that of a remittent fever, and hence the 
daily remission and exacerbation were regarded as the expression of 
the malarial infection. It is merely in some increase of the sweep of 
the thermal wave that the influence of the malarial complication is 
made evident. After the typhoid process has expended itself, and in 
a perfectly legitimate manner, the malarial element begins a disturb- 
ance. Then it is that a remittent, or more frequently a quotidian or 
tertian intermittent, comes on to interrupt and prolong the stage of 
convalescence. 

The Role of Quinine in Malarial Typhoid.— If any additional evi- 
dence were needed to prove the falseness of the conception which re- 
gards the so-called typho-malarial fever as a morbid entity, it is 
afforded us in the behavior of quinine. All the world knows that 



812 



FEVERS. 



quinine manifests no more power to control this than to arrest typhoid. 
There comes a period, however, when the use of quinine is indispen- 
sable. It is when, after the exhaustion of the typhoid process, the 
malarial element initiates a characteristic disturbance on its own ac- 
count. Then, by its timely exhibition, a convalescence that might have 
been protracted and unsatisfactory is rendered shorter and milder. 

The Typhoid State in Remittent Fever.— It is necessary to note 
another source of error in regard to typho-malarial fever. Cases of 
remittent fever of severe form, if not arrested by massive doses of 
quinine, will assume more and more nearly a continued type, and will 
finally pass into a typhoid state. Very often, no doubt, this typhoid 
condition is confounded with typhoid fever, but a study of the mor- 
bid anatomy will disclose the error. 

TYPHUS FEVER. 

Definition. — A febrile affection, self -limited, and characterized by 
profound adynamia, a peculiar petechial eruption, favorable cases 
terminating by crisis at the end of the second week. Typhoid and 
typhus are noAV almost universally regarded as distinct affections. 
Stokes,* however, takes a different position, and maintains that the 
points of resemblance are greater than the differences. 

Causes.- — As a rule, typhus prevails in seaport towns, where it is 
known as " ship-fever " ; but it has under some circumstances ravaged 
continents, as during the great famine periods : Ireland has been deci- 
mated, and, under similar circumstances, Italy and Austro-Hungary 
have been severely visited, f Typhus now prevails in crowded ships, 
asylums, and jails — where great numbers are accumulated together, 
are depressed by poor food and bad air. It is seen in this country 
only at our seaport towns, and the author's personal experience is lim- 
ited to cases observed at the Baltimore Infirmary, admitted to the 
service of the late Professors Power and Chew from ships in the har- 
bor in the years 1850-'53. How evil soever maybe the hygienic influ- 
ences, typhus does not originate spontaneously ; the peculiar germ must 
be introduced from without. Of the nature, form, and condition of 
the germ we know nothing. ' The disease is contagious, and the con- 
tagious principle increases in virulence the more crowded and numer- 
ous the patients within a given area, and the more unfavorable the 
hygienic influences and the bodily state of those attacked. Hence the 
terrible force of the poison during the famine periods in Ireland. The 
disease is more frequent among males than among females, and occurs 
by preference during the most active period of life, or from fifteen to 

* " Lectures on Fever," London, Longmans, Green & Co., 1S74, p. 86. 
t *' Traite de Climatologie Medicale," tome iv, p. 362, et seq. 



TYPHUS FEVER. 



813 



fifty. Like other acute infectious diseases, one attack serves to exempt 
from future attacks. 

Pathological Anatomy. — We do not find in typhus the definite 
series of changes which so individualize typhoid. The solids and 
fluids generally are deeply injured. Vascular turgescence is noted 
in the upper part of the small intestines and the ileum. In the midst 
of stellate or arborescent injection in the ileum, there are sometimes 
small spots of ulceration, not all like the ulcerations of typhoid, and 
occun-ing in only five per cent, of the cases."^ Changes — thickening 
and deposits — in the mesenteric glands are very uncommon. More or 
less congestion of the spleen, liver, and kidneys, with granular degen- 
eration more or less advanced, is noted in a portion of the cases. A 
similar change — granular degeneration — occurs in the heart as well. 
There is present some serum in the sac of the pericardium. The blood 
is dark, fluid, and not firmly coagulable, but thrombi are found adhe- 
rent to the walls of the large veins. There is more or less fluid in the 
subarachnoid spaces, and the membranes and cerebral substance are 
more or less injected. The mucous membrane of the bronchi are 
h^^ersemic and sometimes inflamed, and occasionally atelectasis and 
pneumonia are encountered. The muscles present the changes of 
granular degeneration. 

Symptoms. — There may or may not be a prodromic stage, and, 
when it does occur, it is of short duration. The patient is dull, heavy, 
dispirited, experiences a strong sense of fatigue, has headache, is rest- 
less and wakeful at night. In a few days the effort to keep up is 
abandoned, and the patient betakes himself to bed, thoroughly ex- 
hausted. In other cases, of which the great Irish epidemics have 
furnished numerous examples, the patient is suddenly seized, and 
passes at once into a state of profound adynamia, or he walks to the 
hospital, is put to bed, and in twenty-four hours he lies helpless, coma- 
tose, and sinking. There may be a slight chill at the onset, or nausea 
and vomiting may inaugurate the symptoms. A very severe head- 
ache and pains in the back and limbs are now experienced. The head 
feels hot ; there is much giddiness when the attempt is made to rise ; 
and sneezing, with other symptoms of catarrh, and noises in the ears 
are also experienced. The fever rises rapidly from the beginning, 
the pulse ranges from 90 to 120 at once, and the temperature by the 
third or fourth day has attained to 103° or 104° Fahr. in the morning 
and 105° or 106° in the evening. Again, it sometimes happens, so pro- 
found is the intoxication, that the forces are inadequate to maintain 
the pulse at or above normal and the temperature above 99°. There 
may be high temperature temporarily without any special significance ; 
but persistently high temperature bodes ill. Extreme weakness and a 



Lyons, op. cit., p, 142, et seg. 



814 



FEVERS. 



deep, apathetic listlessness soon come on, when the patient lies on his 
back, oblivious to all about him ; his eyes are half closed, and are dull 
and glazed ; his mouth is half open, the lips dry and cracked, the teeth 
covered with sordes ; his face is dusky, which is the general tint of 
the skin, and the malar protuberance has a reddish-brown color. To- 
ward the end of the first week the characteristic eruption of typhus 
makes its appearance on the back between the scapulse in males, on 
the chest and abdomen in females, and spreads thence over the rest of 
the body. They are a half line to a line in diameter, reddish-brown 
in color, a little elevated above the general surface, disappearing on 
pressure, to reappear when the pressure is removed. They may be 
very numerous, so that a dozen will be contained in a square inch, or 
they may be sparse and larger in size. Successive crops appear, and 
the duration of the eruption stage is from five to seven days, so that it 
may be expected to disappear from the twelfth to the fourteenth day. 
Prognostications may be drawn from the appearance of the eruption. 
If it is rose-colored, the general tint of the skin being good, the condi- 
tion is favorable ; if a dusky-brown, rather livid color, the skin also 
dusky, the condition is unfavorable. Trousseau * formulates the sig- 
nificance of the eruption as follows : " The gravity and duration of 
the malady are in relation to the abundance and depth of color of the 
eruption." Besides the measles-like eruption, which is characteristic, 
there are in some epidemics spots and patches of purpura, of vary- 
ing size, and the larger extravasations known as vibices. Both of 
these indicate a low form of the disease, and are, therefore, symjDtoms 
of evil augury. Sudamina also occur, but these have no special sig- 
nificance, unless differing from ordinary sudamina in the character of 
their contents, which, if bloody, or having a putrescent odor, show a 
bad state of the tissues. At the close of the first or beginning of the 
second week, instead of there being a merely clouded state of the men- 
tal faculties, active delirium may ensue. It may be very violent, the 
patient difficult of control, striking and fighting all who approach, try- 
ing to get out of bed, etc. This condition, which has been happily 
designated delirium ferox, may continue for days and nights, the 
patient sleeping none, there being at the same time intense fever, 
rapid action of the heart, injected conjunctivae, great intolerance of 
light, and contraction of the pupils. But this active and violent 
delirium is much less common than low-muttering delirium in which 
the illusions and hallucinations form the topics of the unintelligible 
rambling. The patient usually lies in an entirely passive state, taking 
food mechanically, sleeping but little, although in a constant sopo- 
rose state, the pulse ranging from 120 to 140, double-beating, easily 
compressible, the surface of the body presenting a dusky, cyanosed 



* " Clinique M4dicale," tome i, p. 299. 



TYPHUS FEVER. 



815 



appearance, and the actual condition being that of profound and in- 
creasing prostration. There is usually some dry cough. The bowels 
are at first rather confined, and during the height of the disease the 
dejections are scanty, rather infrequent, but consist of somewhat loose, 
offensive, dark stools. There is no distention of the abdomen. The 
spleen is enlarged, and can be made out projecting downward. The 
urine is scanty, high-colored, specific gravity high, and usually con- 
tains albumen. During the stupor, urine and faeces are passed in- 
voluntarily. A very peculiar and distinctive odor is maintained by 
many to exist. Trousseau regards it as sid generis; but we believe it 
to be similar to that which is to be detected about all fever-patients 
so oblivious to their natural wants. During the second week the pros- 
tration is so profound that patients die, without any special compli- 
cation, from failure of the heart. The temperature of the skin falls; 
the purpuric spots enlarge ; parts exposed to pressure — the sacrum 
especially — soften and ulcerate ; the pulse becomes small and irregu- 
lar ; the impulse of the heart is scarcely perceptible, and the first 
sound is no longer audible. In this condition the patient may remain 
for a day or two, even longer, suspended between life and death — the 
stupor may deepen into fatal coma, or death may be induced by sud- 
den engorgement of the lungs, or the heart fails, the pulse becomes 
imperceptible at the wrist, and the surface cold_, and covered with a 
cold sweat. Instead of a fatal termination, a large proportion recover. 
About the fourteenth day, if a change for the better is to occur, phe- 
nomena of a rather critical character supervene. The patient falls 
into a quiet sleep lasting several hours, and he awakes refreshed, and 
with consciousness restored, but oblivious of all that has transpired, 
and feeling an extreme degree of feebleness. The pulse lessens in fre- 
quency, but gains in volume ; the tongue begins to clean and is moist ; 
the skin is covered with a warm perspu-ation, and a little appetite is 
felt. The critical phenomena which may accompany this change for 
the better consist of a free sweat, a diarrhoea, or an abundant urinary 
discharge, with large deposits (Murchison*). 

Course, Duration, and Termination, — There are great variations in 
the course of cases of typhus during the epidemics. In the mildest 
cases the pulse may not exceed 100, the tongue may never become dry 
and brown, there may be only temporary confusion of mind, and some- 
what troubled sleep. There are extreme cases, in which the patient is 
stricken down with the intensity of the poison, and at once passes into 
a state of profound prostration, with disorganization of the blood ; 
and, without any complication to account for it, life is extinguished in 
a few days after the onset of the disease. Usually, however, the fatal 
result may be referred to the rise of some complication. Some of the 



* Murchison *' On Fevers," op, cit. 



816 



FEVERS. 



most important are the pulmonary : bronchitis, hypostasis, pneumonia, 
gangrene of the lung, and pleurisy. During the course of typhus, 
frequent examinations should be made of the thoracic organs, since 
the insensibility is so profound that the patient may not present any 
indications of the complications. Especially should an increased ra- 
pidity of breathing become manifest, or the alsQ of the nose labor, or 
the lividity of the face deepen, attention should at once be directed 
to the state of the thoracic organs. The most usual of the thoracic 
complications is bronchitis, and it is not always shown by cough, but 
only by moist rales. The danger consists in an extension to the 
smaller tubes, and the association of hypostatic congestion with capil- 
lary bronchitis. When the adynamia is very deep, the tubes may 
become paretic, and can not expel the accumulating mucus, death oc- 
curring in asphyxia. The association of hypostatic congestion with 
bronchitis is the most usual cause of death in typhus, taking the gen- 
eral order of cases. Pneumonia is uncommon, but gangrene is com- 
paratively frequent in famine-typhus. Thrombosis of the femoral 
artery sometimes occurs, but the chief complications on the part of 
the blood are those due to its disorganization : purpuric spots, haemor- 
rhages by the nose, bronchial tubes, stomach, intestines, and kidneys, 
and a more or less extensive general cyanosis. Imbecility and mania 
are sometimes sequences of typhus, but there are complications of a 
paralytic kind occurring during the course of the fever, or during con- 
valescence, such as hemiplegia, paraplegia, or affections of the special 
senses, amaurosis, and especially deafness. These are usually tempo- 
rary, and due to the extreme degree of anaemia produced by the fever, 
but some of them are more permanent, as the deafness due to suppu- 
ration of the middle ear. Complications on the part of the skin are 
often very severe, notably the extensive bed-sores, gangrene of the 
skin, and furuncles. A whole extremity may become gangrenous. 
Erysipelas of the scalp and face, suppuration of the parotid gland, and 
buboes, are also encountered. All of these complications increase the 
gravity of the case, and in proportion to their importance. The dura- 
tion is also more or less influenced by the complications. The ordinary 
duration of a mild, uncomplicated case is about three weeks. The 
Germans recognize an abortive form of typhus, terminating by crisis 
about the seventh day, but such cases, it seems to the author, belong 
to a different order. A case of typhus may be protracted by compli- 
cations four, five, or six weeks. Even in the severer epidemics the 
majority recover. Much depends on the type of the cases. Those 
characterized by intense fever and active delirium are called inflam- 
matory ; those in which the merely nervous symptoms, as delirium, 
stupor, subsultus tendinum, predominate, are designated ataxic y and 
those in which a profound prostration comes on are known as ady- 
namic (Murchison). In the severe epidemics which have visited Ire- 



RELAPSING FEVER. 



817 



land and India one fifth have proved fatal, and this was the mortality 
at the London Fever Hospital for fourteen years. In some epidemics, 
the mortality has risen to forty per cent., and even higher, and in 
others has fallen to eight per cent. The type of the epidemic, as "well 
as of individual cases, is, therefore, a large factor in determining the 
mortality. The mean mortality is from fifteen to twenty per cent. 
The disease is more fatal in males than in females, and is less fatal in 
childhood, the mortality increasing with age. 

Diagnosis. — Stokes is the ouly author of any prominence advocating 
the identity of typhoid and typhus. The prodromic stage is more 
usual and protracted in typhoid ; the onset of stupor and delirium is 
earlier and more pronounced in typhus ; in typhoid there are meteor- 
ism, gurgling in the right iliac fossa, and diarrhoea— in typhus these 
are wanting ; in typhoid there is a roseola eruption of a small number 
of spots ; in typhus there is a petechial eruption, which is abundant 
over the body ; the duration of typhus without complications is about 
two weeks, often terminating with crisis — of typhoid, four weeks, by 
slow decline of fever ; on post-mortem examination, thickening and 
ulceration of Peyer's patches and of the solitary glands and enlarge- 
ment and softening of the mesenteric glands are seen in tyj^hoid, 
while no similar or corresponding changes take place in typhus. 

Treatment. — The same means of treatment pursued in typhoid are 
equally applicable here, except that the adynamic condition appears 
sooner, and is more profound, requiring a somewhat earlier resort to 
stimulants. The alimentation should be carefully prescribed from 
the beginning, and should consist of milk, eggs, animal broths, and a 
moderate quantity of wine, which should be changed to whisky or 
brandy as the prostration increases. Still more than in typhoid is it 
necessary in typhus to keep the temperature within safe limits by the 
use of antipyretics. Cold baths, or the wet pack, quinine, and digitalis, 
are used as in the treatment of typhoid, under the same rules and reg- 
ulations. As certain critical phenomena may ensue at or about the 
end of the second week, it is important to be prepared for them, lest 
the revolution which then takes places may tax too heavily the vital 
resources. As typhus is distinctly contagious, isolation of the patient 
is demanded by every consideration, and all of the patient's excretions 
should be disinfected and removed without delay. 

RELAPSING FEVER. 

Definition. — This is an acute, infectious, febrile disease, self -limited, 
and characterized by the occurrence of a febrile paroxysm, lasting 
about one week, succeeded by an entire intermission of four or five 
days' duration, which is in turn followed by a relapse like the first 
seizure, although shorter. 
54 



818 



FEVERS. 



Causes. — Relapsing fever is a distinctly contagious affection. Some 
excellent illustrations of the modes in which it may be communicated 
have been narrated by Parry,* and every epidemic furnishes examples. 
The poison acquires the greater activity the more filthy, crowded, and 
unhealthy the population amid which it prevails. The larger the 
number of sick, ill with the disease, crowded into a given locality, and 
the more unhygienic the local conditions about the sick, the more viru- 
lent becomes the poison. Articles of clothing which have been about 
the sick will retain the contagious principle for a long time, and those 
who have been in the presence of the sick can convey the poison to 
the healthy at a distance. It seems in a high degree probable that 
drinking-water may be contaminated and spread the poison. So rap- 
idly are members of a family attacked, after one ca'se has been intro- 
duced, that some general cause might be supposed to act on all simul- 
taneously. The disease attacks by preference the young, the liability 
lessening after thirty, and apparently ceasing after fifty. In this dis- 
ease we seem nearer than in almost any other to a correct knowledge 
of the nature of the morbific principle, since the discovery by Ober- 
meier in 1873 of a minute organism in the blood of relapsing-fever 
patients. Unlike most of the other fevers, the occurrence of one at- 
tack of relapsing fever does not purchase an immunity against subse- 
quent attacks ; indeed, the liability to it seems rather increased by pre- 
vious attacks. An intimate relation apparently exists between relapsing 
fever and typhus, for Lebert has ascertained that, of fifty-three cases 
of relapsing fever, all were attacked with typhus within a few weeks to 
several months. Although the natural home of relapsing fever is Ire- 
land, it has spread over England, on to the Continent, and has reached 
this country, distinct epidemics having occurred since 1850 in New 
York, Philadelphia, and other cities. It occurs at all seasons. 

Pathological Anatomy. — The alterations produced by relapsing fever 
are by no means characteristic. During life minute organisms are 
found in the blood, but, according to Lebert,t " they were searched for 
in vain in the spleen, lungs, and other organs." During the primary 
attack and relapse these organisms are present, but they disappear, or 
usually do, during the period of intermission. These bodies consist of 
minute spiral filaments, constantly in motion. They never exceed O'OOl 
mm. in diameter, and 0*15 to 0*2 mm. in length (Lebert). The very 
lively, twisting, and elongating motions of these spiral bodies cease as 
the blood coagulates, and those observed in the serum of the blood are 
often embraced in a granular substance, probably albuminous. J; The 

* Dr. J. S. Parry, "The American Journal of the Medical Sciences," October, 1870. 
f Ziemssen's " Cyclopaedia," vol. i, op. cit. 

X Dr. Paul Guttmann (" Verhandlungen der physiologische Gesellschaft zu Berlin," 
No. 7, 1880) has examined the blood of more than two hundred cases of relapsing fever, 
and finds the characteristic £pirilli of Obermeier only during the pyretic period. These 



RELAPSING FEVER. 



819 



relative proportion of white blood-corpuscles is increased. The spleen 
is usually considerably enlarged, and may be either firm or soft. " Mil- 
iary aggregations of a dull-yellow color, and containing granular de- 
tritus, with occasionally cell-elements and free nuclei," are found in the 
spleen in some cases, and in other cases " wedge-shaped infarctions." 
These may be supposed to have their origin in embolisms formed by 
masses of the spiral organism. The liver is also somewhat enlarged, 
and the acini are in many instances pale and clouded ; and there are, 
rarely, it must be admitted, minute deposits like those mentioned as 
present in the spleen. The gall-bladder is full. The kidneys, like the 
liver and spleen, are somewhat swollen ; the cortex is pale, and cloudy 
swelling and granular infiltration are to be seen in the tubules. In 
the intestinal canal some thickening of the solitary glands and patches 
of Peyer occurs, also in the mesenteric glands ; but these changes are 
trivial as compared with those of typhoid fever. Sometimes in vari- 
ous parts of the mucous membranes minute extravasations of blood 
are found. The only change in the heart is a granular condition of 
its muscular tissue, such as occurs in febrile affections, and a similar 
change is to be seen in the muscles, generally due to the same 
cause. 

Symptoms.— From the period of exposure, or of reception of the 
morbific material, until the first phenomena of the disease are manifest 
— the incubation — about five to seven days elapse. This is not invari- 
able, and must therefore be regarded as a close approximation only. 
There is no real prodromic period. Just as the disease is about to 
appear the patient experiences a general malaise — some pains in the 
head and limbs, wakefulness, loss of appetite, etc. The malady begins 
rather abruptly with fever, in only one half of the cases is there chil- 
liness, and in a much smaller number a distinct rigor. In some epi- 
demics there are irregular chills, and occasional sweats for the first 
two or three days, simulating an intermittent fever. In many cases 
the fever is high and the symptoms severe from the beginning ; in 
other cases the patient keeps about for the first few days. With the 
initial fever there are usually nausea and vomiting, and, if not in the 
beginning, in a very short time there is a marked degree of debility. 
The fever is of the remittent type, with a morning remission and an 
evening exacerbation — the morning temperature being at 102° to 103° 
Fahr., and the evening temperature at 104° to 105°. The pulse cor- 
responds, ranging from 110 in the morning to 130 in the evening, and 
is rather weak, usually dicrotic, or wanting in tension. The tongue 
is coated and soon becomes very dry and sore ; the bowels are consti- 
pated. The chief source of suffering at the outset is the pain in the 
back and limbs, but all the muscles of the body soon become the seat 

new observations confirm what is stated in the text. Dr. Guttmann further shows that 
the spirilli are genuine parasites. (See also Virchow's '* Archiv," Band Ixxx, s. i, 1880.) 



820 



FEVERS. 



of very violent grinding, piercing, lancinating pains, and these priiea 
are increased by movement or pressure. The most aggravated of 
these pains are those felt in the calf of the leg. The headache, which 
was so pronounced in the beginning, lessens somewhat in severity as 
the muscular pains develop. About the second day a painful sense of 
weight and pressure is experienced in the right and left hypochon- 
drium, especially in the left, and is caused by enlargement, with con- 
gestion, of the liver and spleen. The spleen especially enlarges very 
considerably, projecting below the ribs. The area of hepatic dullness 
is also much increased, and the margin of the liver can be felt several 
fingers' breadths beyond the ribs. This increase in the dimensions of 
these organs begins on the second day, and increases day by day, to 
diminish during the interval or intermission. Besides the increase in 
volume, these organs become very sensitive to pressure, and continue 
tender as long as they are enlarged. There is no tympanitic disten- 
tion of the abdomen, no diarrhoea, no rose-spots, but more or less vom- 
iting persists during several days, the vomited matters consisting of a 
greenish, acid fluid. There is no delirium, the nights are much dis- 
turbed by pain, but the mind is unclouded. The urine frequently 
contains albumen, but its composition in other respects is that of the 
urine of febrile diseases in general. More or less sweating occurs, but 
no amelioration of the fever is produced, for the skin continues hot, 
while there is a general moisture of the surface. The fever, the pains, 
the nausea and vomiting, the tumefaction of the liver and spleen, con- 
tinue up to the end of the paroxysm. It is not surprising that, under 
these circumstances, there should be weakness and emaciation. In a 
small proportion of cases jaundice appears at some period during the 
first paroxysm. Toward the end of the first week, on the fifth, sixth, 
or seventh day, all of the symptoms attain their maximum and the 
case looks truly formidable, when a sudden defervescence takes place, 
and with it a remarkable diminution in all of the symptoms. Profuse 
sweating sets in, and the temperature falls to normal and below, a 
variation of five or six degrees taking place from night to morning. 
The pulse also descends from the high point at which it had been at 
the maximum, to the normal, or even below. Corresponding changes 
ensue in the other symptoms. A feeling of comparative comfort is 
substituted for the severe pains ; appetite replaces nausea or disgust 
for food ; the bowels act normally ; the swelling and tenderness of the 
liver and spleen disappear, and the jaundice, if present, begins to fade ; 
the tongue clears off ; sleep is restored, and the strength gains rapidly, 
so that in a day the patient is disposed to get up and regards himself 
as well, although somewhat weak. The improvement continues, and 
hence it is a matter of extreme surprise to the patient, if unfamiliar 
with the nature of the malady, to be attacked with a relapse. The 
period of intermission is not a fixed period, and varies from four days 



RELAPSING FEVER. 



821 



to one week, very rarely to two weeks. Complete recovery has not 
therefore taken place when the relapse occurs. Quite suddenly, in the 
afternoon, in the evening, or more frequently at night, the relapse 
comes on with a chill which is rather exceptional, or a sense of chilliness, 
or with fever only. The relapse, as a rule, repeats the symptoms of 
the initial seizure, except that its course is less severe and of somewhat 
shorter duration ; but the pains, nausea, and vomiting, enlargement of 
the liver and spleen, are very much the same. The fever has more of 
a remittent type, and the sweats have a somewhat critical aspect, for 
more relief is afforded by them than during the primary paroxysm. An 
attempt at critical phenomena may be made a day or two before the 
real crisis ; there may be a considerable sweat and a marked fall of 
temperature; but the effect is not maintained and the temperature rises 
again. The final defervescence occurs from the third to the fifth day, 
and usually at night, when a profuse sweat occurs, and the temperature 
and the pulse-rate fall below normal. The crisis may be postponed to 
the seventh day, but this is not usual. A second, a third, even a fourth 
relapse has been noted in some epidemics. The symptoms are the 
same, but the more numerous the relapses, the more reduced must the 
patient become by^a repetition of the suffering. 

Course, Duration, and Termination. — The whole course of an ordi- 
nary case of relapsing fever is concluded within three weeks, unless 
there be several relapses. At the conclusion of the relapse, the patient 
lies in a condition of great comparative comfort, but much emaciated 
and quite exhausted. The ansemia is very marked, there is more or 
less oedema of the ankles, the eyelids are puffy, and the sclerotic 
pearly white. The convalescence is very slow. Much, of course, de- 
pends on the violence of the seizures, and the number of relapses. 
Age appears to have an influence, for, in children under twelve. Parry 
observed that the course of the disease was shorter and milder. There 
are also differences in different epidemics in respect to the duration 
and severity of the disease. The usual termination is in health, the 
mortality being about two to three per cent. Complications may have 
a very great influence over the result. Bronchitis, catarrhal pneumo- 
nia, and pleuritis, occur in some epidemics, and laryngitis has required 
tracheotomy. At the period of crisis, haemorrhages may occur, notably 
epistaxis and local paralyses — of the deltoid, for example — have been 
observed. Diarrhoea has occurred at the crisis instead of a sweat — in 
some epidemics increasing the mortality. A pregnant woman ill with 
relapsing fever is almost certain to abort, and hence this must be 
regarded as a serious complication. At the period of crisis, fatal syn- 
cope has occurred without any apparent reason. The extraordinary 
revolution which th6n takes place may impose too great a strain on a 
weak heart. The persistence of changes in the liver and spleen, after 
recovery from the fever, must place these affections among the 



822 



FEVERS. 



sequelae. In the same category is a form of ophthalmia which has 
occurred after certain epidemics. 

Treatment. — The remedial management of relapsing fever must 
necessarily he expectant. We possess no agent to prevent the develop- 
ment of the spirilla in the blood, and we do not know how this para- 
site enters the blood, or whence it comes. The treatment of the fever 
would seem to require the use of antipyretics, but their utility is very 
limited, owing to the short duration of the paroxysm.* The best means 
of relieving the severe pains are the hypodermatic injection of mor- 
phine and the wet pack. Opium by the stomach has but little effect, 
apparently, in this disease. For the nausea, the best remedy, probably, 
is carbolic acid (half a grain) administered in cherry -laurel water. For 
the nocturnal pain and wakefulness, a combination of chloral and mor- 
phine promises best. The enormous production of spirilla during the 
paroxysms of fever and their disappearance in the intermission are 
strong arguments in favor of the administration of parasiticides. The 
use of quinine has been quite fruitless. But a more systematic admin- 
istration of the sulphites and the disengagement of sulphurous-acid 
gas in the air of the sick-apartment should be attempted. At the 
period of crisis, syncope may be prevented by the timely use of alco- 
holic stimulants. It is especially during the period of intermission 
that an attempt ought to be made to prevent the new development of 
the spirilla which it is supposed then takes place. Suitable food, iron, 
and other tonics should be given to improve the quality of the blood ; 
the increased volume of the spleen reduced, and the overproduction 
of white corpuscles prevented by the administration of quinine and er- 
gotin, and an attempt made to prevent the new growth of the parasite 
by the free use of the sulphites and other parasiticides. 

YELLOW FEVER. 

Definition. — Yellow fever is an acute, infectious disease, occurring 
only south of 48° north latitude, in regions having a mean annual tem- 
perature of not less than 70° Fahr., endemic on the seacoast, and spo- 
radic elsewhere under an elevation less than twenty-five hundred feet 
above the sea-level, the germ being introduced and certain localizing 
conditions favoring its development. 

Causes. — Pursuing the plan heretofore followed, the author will not 
occupy space with controversial questions. The cases (private) seen by 
the author occurred in the Mississippi Yalley, and were encountered at 
Cincinnati, having come there from infected localities in the South, 

* As this work is going through the press, Dr. Eiess, of Berlin, reports that he has 
found the salicylate of soda remarkably effective in reducing the temperature, and, if 
given in large doses for some days, will lessen the severity, and even prevent the relapse 
("Berliner klinische Wochenschrift," No. lii, 1879). 



YELLOW FEYER. 



823 



especially Mempliis. It seems necessary to the production of yellow 
fever that a peculiar germ or morbific principle be introduced from 
without. For the further development of this germ it is necessary 
that there be a concurrence of certain telluric and personal condi- 
tions. It is needless to discuss here whether the poison ever arises 
spontaneously in its natural habitat under the necessary conditions. 
Of the nature, form, and composition of the morbific principle, nothing- 
is as yet known, and the last investigations in regard to it have proved 
as barren of results as the preceding one. We know that a mean an- 
nual temperature of about 72° is necessary to its activity, and that cold 
— a frost — suflices to destroy it. A fall of temperature short of that 
necessary to suspend the activity of the poison increases the mortality 
from it. Yellow fever occurs in maritime cities first, and extends 
thence to towns and cities having direct communication with them by 
river or by railroad. Cities and toAvns, removed, by reason of their 
situation, from intercourse with infected maritime cities, escape epi- 
demic visitation. The disease does not spread from city to city so 
rapidly as men move from one to the other. A germ or germs are 
introduced. Accumulated filth, decomposing animal and vegetable 
matters, bad or no drainage, crowding, and other hygienic evils, are 
indispensable to impart the necessary vitality. Lodging thus in a 
suitable soil, and with the appropriate atmospherical conditions present, 
the disease-germs grow and infect those in the proper personal state 
to receive the poison. After a time, from this newly infected locality, 
germs are transmitted to other localities. The conditions existing on 
shipboard seem peculiarly favorable to the growth of the poison. Next 
to the ship, as a nidus for yellow fever, is the large maritime city, 
situated at the outlet of a great river, subject to annual overflow and 
filled with all the materials of insalubrity.* To these must be added 
the atmospherical peculiarities of July, August, and September. When 
the disease-germs are introduced, and the localizing conditions are 
favorable, not all persons are attacked. Some present a peculiar sus- 
ceptibility, others insusceptibility to the action of the poison. Race 
exercises a remarkable influence, the pure negro possessing a singu- 
lar immunity against the infection, provided he has not lived outside 
of the yellow-fever zone and returned to it just before an outbreak. 
Any considerable admixture of white blood destroys the protection. 
Whites are more susceptible the farther removed from the yellow- 
fever zone they have lived previously. Long residence in the infected 
locality, especially passing through a period of epidemic prevalence of 
t±iG disease, and still more effectually passing through an attack, pro- 
cure more or less complete immunity ; but this immunity may be lost 

* See Dr. Woodhull's (Sur;::eon U. S. A.) account of " The Causes of the Epidemic of 
Yellow Fever at Savannah, Georgia, in 18'76," " The American Journal of the Medical 
Sciences," July, 1877. 



824 



FEVERS. 



and susceptibility restored by any protracted stay outside of the yellow- 
fever zone. This process of hardening against the reception of yellow 
fever is called accUmatioii. It is not by personal contact that the dis- 
ease is communicated — in other words, it is not a contagious * but an 
infectious disease, and it is not against individuals that quarantine 
restrictions should be enforced, but against articles of clothing, bed- 
ding, or the like, or against all fomites. The condition of the indi- 
vidual opposes or favors the reception of the poison. Besides all those 
conditions which favor or retard the spread of the poison above men- 
tioned, must be stated the habits of the individual. All excesses 
in drinking or venery either help the reception of the poison or in- 
crease the virulence of its action in the body. All depressing moral 
emotions, especially fear, act unfavorably. 

Pathological Anatomy. — Not much wasting of the body is observed, 
and the post-mortem rigidity is usually well marked. The color of 
the skin is light or dark yellow, a change which appears to be never 
wanting in genuine cases. The skin is also stained by hgemorrhagic 
extravasation, ecchymoses, vesicular eruptions, and gangrenous vesica- 
tions at points where irritating applications had been made. The dura 
mater is often yellow, the sinuses engorged, the vessels of the pia con- 
gested, rarely haemorrhage in the subarachnoid spaces or bloody serum, 
the cerebrum not abnormal, the ventricles containing a little serum, 
very rarely bloody serum, and similar conditions in the spinal canal, 
there being nowhere in these organs any evidences of inflammation. f 
On the other hand, inflammation of the spinal arachnoid in the lumbar 
and sacral regions has been reported, but the constancy of such lesions 
must be regarded as doubtful. The changes which have been observed 
in the coeliac and hepatic plexuses, and which consist in an inflamma 
tion of the neurilemma, must also be considered as of doubtful sig- 
nificance. J; More or less congestion of the lungs, chiefly hypostatic, is 
usual, and the bronchial mucous membrane presents the usual appear- 
ance of passive congestion. The sac of the pericardium contains more 
or less serum, as a rule, and it is rarely bloody. Purpuric spots are 
occasionally seen on the pericardium, endocardium, and on the surface 
of the heart itself. The muscular tissue of the heart may be un- 
changed, but it is very often more or less softened by granular de- 
generation. Various changes observed in the composition of the 
blood are described, but thus far nothing peculiar to yellow fever has 

* This question is most elaborately treated by La Roche (" Yellow Fever," vol. ii), 
who finds the arguments against contagion stronger than those in favor. 

f Lyons, op. cit., Appendix, " Pathological Anatomy of the Yellow Fever of Lisbon," 
1857. 

:{: The official commissions appointed to investigate the nature of yellow fever have 
not contributed any new facts, or made any discoveries that help us to a better knowledge 
of the disease. 



YELLOW FEVER. 



825 



been discovered. It is true, Dr. Joseph G. Richardson, of Philadel- 
phia, supposed he had found a peculiar bacterium, which he described 
as bacterium sanguinis, in the blood, but other competent observers 
have been unable to confirm his observations. A rapid crenation 
of the red-blood corpuscles has been noted by Dr. Schmidt,* of New 
Orleans, which he regards as a retrogressive change probably not 
peculiar to yellow fever. No alterations have been observed in the 
white blood-corpuscles, although there seemed to be some slight increase 
in their relative proportion. The most characteristic of the morbid 
alterations of yellow fever are those of the liver and other abdominal 
organs. In the Lisbon epidemic, in the epidemics of this country, 
and elsewhere, the liver has always been remarkably altered. Exte- 
riorly, it most usually presents a fawn-yellow, or buff-color, which is 
pretty uniform throughout the whole organ, although here and there 
may be patches of a deeper color. Various shades of the above-de- 
scribed tint are observed in some cases and in different epidemics, 
because the degree to which the alteration has attained differs some- 
what ; but when the ordinary liver-brown color is present, on minute 
examination, the liver is found to be altered in the usual way. The 
change taking place in the liver consists of a fatty infiltration, and 
a fatty degeneration of the protoplasm of the hepatic cells. In an 
advanced case, the hepatic cells are smothered in a mass of fat-cells 
and granules. More or less coloration of the cells about the radicles 
of the blood-vessels with blood and bile-pigments is to be seen. The 
stomach-veins are deeply engorged. This engorgement may be gen- 
eral or partial, aud if partial the mucous membrane about the cardiac 
extremity is chiefly affected. Patches of vascularity, punctiform con- 
gestion, ecchymoses, and purpuric spots, have been observed in different 
cases. The epithelium is usually intact. More or less " coffee-ground " 
matter, or dark, coffee-colored liquid, containing coffee-grounds mixed 
with it, is found in the stomach. The black vomit consists chiefly 
of blood and epithelium ; the blood-corpuscles are deprived of their 
haemoglobin, which is separate ; and the rest is made up of white cor- 
puscles, epithelial cells, and debris. The spores and fully developed 
yeast-plants {Torida cerevisice) are found in the vomited matters, and 
other fungi quickly develop in them on standing. The mucous mem- 
brane of the small intestine presents the same deep congestion as that 
of the stomach. In more than one third of the cases in the Lisbon 
epidemic there was present in the intestine extravasated blood in various 
stages of the alterations produced by the intestinal juices, and which 
presented an inky blackness, a reddish-brown or a bloody tint. In quan- 
tity the extravasation was sufficient to distend the small intestine in 
some instances, and was generally considerable. The glandular appa- 
ratus of the small intestine has been usually represented as intact in 
" New York Medical Journal," February, 18Y9. 



826 



FEVERS. 



all the various epidemics. No characteristic changes take place in the 
spleen. The kidneys are rarely normal. A considerable hyperjemia 
of these organs seems to be nearly constantly present. The epithe- 
lium of the tubules undergoes granular degeneration, and this takes 
place both with the straight and convoluted tubes. Fatty degenera- 
tion follows in those cases where death has been long enough postponed 
to give the necessary time. The urine undergoes important altera- 
tions. The uric acid and urea diminish and ultimately disappear, and 
are replaced by leucin and tyrosin, while albumen appears, at first in a 
mere trace, but increasing in amount. The urine also assumes a deep 
color from the quantity of blood-pigment and bile-pigment present in 
it, and is denser and more viscid (Yidaillet*). Schmi.dt calls attention 
to changes in the supra-renal capsules, but they do not seem to be dif- 
ferent from the appearances observed in numerous maladies. 

Symptoms. — First Stage. — The period of incubation varies within 
wide limits, if conclusions are drawn from exceptional cases, f Usually, 
from the period of exposure to and reception of the disease-germ, 
from one to three days will elapse. The disease begins in two modes 
— one with prodromic symptoms or gradually, and the other very sud- 
denly. Soon after the reception of the poison, in many subjects, there 
ensue impaired appetite, a feeling of debility, headache, muscular 
pains, for two or three days, when the disease sets in with a chill, or a 
feeling of chilliness followed by fever. In other cases there are no 
prodromal or premonitory symptoms, and the ^Datient is seized appar- 
ently while in full health, walking, at work, asleep, with a chill, some- 
times a severe rigor, and the fever comes on immediately. Yery 
rarely have been witnessed in recent epidemics those formidable cases 
in which the patients in apparently full health w^ere stricken as it were 
with a heavy bar on the back, falling at once into a condition of pro- 
found prostration, and dying collapsed in a few hours. These cases 
were known as coiqy de harre^ or stroke of the bar, because of the in- 
tense violence of the sudden pain in the back and loins. In every epi- 
demic, however, there are cases characterized by profound blood-poi- 
soning and rapid termination in collapse. These variations will be 
mentioned presently, l^ow we are concerned with the ordinary course 
of the disease. The fever rises rapidly and reaches its maximum on 
the evening of the first or, second day (103°, 104°, 105°). According to 
the tracings of Faget, as given by Sternberg, J "in sixteen the acme is 
reached on the first day; in twenty-three during the first two days " — 
the whole number of observations being twenty-six. The onset of the 

* "Archives Generales de Medecine," November, 1S69. 

f La Roche, "Yellow Fever," vol. i, p. 511, Philadelphia, 1855. 

\ " On the Nature and Duration of Yellow Fever, as shown by Graphic Temperature 
Charts of Typical Cases, etc.," " The American Journal of the Medical Sciences," July, 
1875, p. 99. By Dr. George M. Sternberg, U. S. Army. 



YELLOW FEVER. 



827 



disease causes great disquiet, and the victims are restless and disheart- 
ened. The face appears anxious and flushed ; the eyes moist and 
bright, and the conjunctivje injected. There are decided headache, 
throbbing of the temples, general muscular pains, but especially severe 
and depressing pains in the back and loins, which in their worst form 
constitute the dreadful coiq) de harre. Early in the disease, and, ac- 
cording to some, before the outbreak, a peculiar odor is perceived, and 
by many is regarded as distinctive of yellow fever. The odor is rather 
cadaveric and diffusible, but much that is asserted in regard to it seems 
to the author very apocryphal. The tongue is heavily coated with a 
thick, whitish fur, and is red at the tip and edges, the swollen papillse 
projecting above the surface. The palate mucous membrane becomes 
red and oedematous. The stomach is from the first irritable ; the epi- 
gastrium is tender to the touch ; cold drinks are taken with great 
avidity, excite pain, and are rejected mth a good deal of painful retch- 
ing at first ; and the stomach is equally intolerant of all kinds of food. 
Sometimes there is diarrhoea, but usually the bowels are constipated. 
The vomited matters at this early stage consist of particles of food, 
mucus, and bile, and flocculi of brownish or chocolate colored material 
— the forerunner of the dreaded black vomit. The stools are pasty and 
grayish, but constipated. The urine lessens in quantity, darkens in 
color, and distinct traces of albumen are now discovered in it. The 
pulse is rapid, strong, with high tension in some cases, weak and di- 
crotic in others, and the pulsations range from 90 to 120. When the 
temperature reaches its maximum, usually on the second day, it begins 
to decline by lysis, a remission occurring about the fourth day, ter- 
minating the first stage. In the mildest cases the remission occurs on 
the second day, and it may be postponed to the sixth day or longer. 
During the period of maximum temperature and the first stage, besides 
the symptoms already mentioned, there may be considerable restless- 
ness and active delirium, the patient being kept in bed with difficulty, 
or the delirium may present the appearance of delirium tremens — an 
active, busy, and trembling delirium. At this stage there may begin 
to appear a jaundiced tint of the skin ; the urine may contain bile-pig- 
ment, the stools having a clay-color, which is, however, not usual. 
There may also occur haemorrhages from the nose, from the gums, 
and also from the stomach ; but it is only in the severe cases that these 
haemorrhages occur so early, and hence they are of evil augury. 

Second Stage. — The decline of temperature which marks the end 
of the first stage may proceed to a complete intermission. In all of 
the cases collected by Sternberg, " a complete intermission, or nearly 
so, was found on the morning of the third day." According to others, 
Haenish for example, there is. not a complete defervescence — only a 
remission — in a majority of the cases. With the decline in tempera- 
ture there occurs a most favorable change in the condition of the 



828 



FEVERS. 



patient. The delirium subsides, the pains cease, the stomach may be- 
come quiet, some critical evacuation, as a sweat, an attack of diarrhoea, 
or an epistaxis, may occur, and convalescence be at once established. 
Instead, however, of these favorable symptoms the delirium may per- 
sist, the irritability of the stomach may increase, albumen, if it has not 
been in the urine, may now appear, the pulse may become weak, and 
the condition of the patient may grow rapidly worse, notwithstanding 
the marked defervescence and the relief to the symptoms which may 
at first be caused by the remission. The period of time occupied by 
the remission varies considerably, and is from one to four days. 

Third Stage, — The remission disappears and the temperature rises 
again, but not so rapidly as during the first stage, the maximum of 
about 104° being reached on the second day. If the active delirium 
persists, the patient becomes unmanageable, refuses food and drink, 
the leg-muscles are thrown into violent cramps, jaundice deepens, 
black vomit comes on, the pulse fails at the wist, and death closes the 
scene suddenly in the midst of violent delirium. In much the largest 
proportion of cases, the mind is unclouded, and the moral state that of 
complete apathy and indifference. The strength rapidly declines, and 
the pulse is small, weak, and irregular. The jaundice passes from the 
characteristic lemon-color to a deep mahogany, and haemorrhages pour 
out from the various mucous surfaces and from the skin ; the nose 
bleeds, and blood is vomited, passed by stool, and less often expec- 
torated. The gums are soft, spongy, and bleed with a touch, and 
rarely the ears bleed. The most striking and characteristic phenom- 
enon is the haemorrhage into the stomach and the return of the blood 
in the form of " black vomit." Even during the first stage, small 
flocculi, of a chocolate-color and composed of altered blood, are seen in 
the vomited matters, but the " coffee-grounds " do not appear usually 
until the second, or stage of remission, and often indeed not until the 
third stage. The urine constantly lessens in amount ; the urea disap- 
pears ; blood-pigment distills through in large quantity ; the albumen 
increases, and very soon, in some cases, entire suppression occurs. 
Under these circumstances, somnolence, stupor, and ultimately coma 
supervene. Partial convulsions, hiccough, and Cheyne-Stokes breathing 
are often observed in these ursemic cases. The temperature also great- 
ly declines toward the end — to 100° even ; and it is a curious fact that 
the action of the heart continues for a time after the respiration and 
pulse at the wrist have ceased. If the case take a favorable turn dur- 
ing the third stage, the temperature descends to normal very abruptly, 
and an improvement in the condition of the patient at once occurs. 
The vomiting stops, and a little aliment may be taken ; the kidneys 
act freely, the circulation improves, and very gradually convalescence 
is established. 

Course, Duration, and Termination. — There are several forms of 



YELLOW FEVER. 



829 



yellow fever, whicli differ sufficiently to require some special consider- 
ation. Many divisions have been made, but in the following forms are 
comprehended the most important varieties — the algid, the sthenic, the 
hsemorrhagic, the purpuric, the typhous (Lyons). The purpuric form 
is, however, only the hsemorrhagic modified. Excluding this, we have 
four varieties of the disease, capable of ready clinical distinction. The 
algid form occurs in subjects debilitated by want and misery. The 
surface is cold, the face sunken and of a livid hue, the extremities blue, 
cold, and shrunken, the skin covered with purpuric patches, the pulse 
small and feeble, the temperature in the axilla at 96° Fahr. Such 
symptoms are not present merely at the outset, but continue to the 
end. Black vomit occurs early, and the hsemorrhages take place from 
all the mucous surfaces. In the sthenic form, the opposite conditions 
prevail. The robust, at the prime of life, are the subjects. High 
fever, severe headache and lumbar pain, delirium of an active kind, 
early jaundice, having the lemon-tint, and less of the black vomit, are 
the most characteristic features of this form. In the hoemorrhagic 
form, the peculiarity consists in profuse and simultaneous discharges 
of blood, effused at various points. Black vomit and intestinal haem- 
orrhage, uterine and renal haemorrhage, simultaneous bleeding from 
the eyes, nose, ears, and mouth, and effusion of blood from any acci- 
dental abrasion, give to this form a distinct individuality. In the 
typhous form are presented symptoms which ally these cases to other 
typhous j)rocesses. They are characterized by stupor, prostration, 
sunken countenance, suffused eyes, dorsal decubitus, low-muttering 
delirium, in addition to the usual and ordinary symptoms of the dis- 
ease. The mortality from yellow fever is largely influenced by the 
type of the prevailing epidemic, and also by the local conditions, and 
by the form of the seizure, whether algid, hsemorrhagic, sthenic, or 
typhous. It necessarily varies much, and between such wide limits as 
from fifteen to eighty per cent. More men die than women and chil- 
dren. The habits of the individual as to temperance enter seriously 
into the prognosis, since the mortality among spirit-drinkers is very 
high. All circumstances which act to depress the vital forces increase 
the severity of an attack. The early occurrence of black vomit and 
suppression of urine are very ominous symptoms. 

Diagnosis. — The only disease with which yellow fever is likely to 
be confounded is remittent fever with jaundice. The distinction rests 
on the temperature line and the occurrence of black vomit. The re- 
missions of malarial fever are quotidian or tertian, and the fever of the 
first stage of yellow fever is continued until the defervescence. No- 
thing like black vomit occurs in malarial fever ; while remittent fever 
is promptly broken up by efficient doses of quinine, this remedy has no 
influence on yellow fever. Again, remittent fever prevails much more 
widely than yellow fever. It is only within the yellow-fever zone 



830 



FEVERS. 



that a question of differentiation can arise. When an epidemic influ- 
ence is at work, there can be no difficulty in the diagnosis after the 
first cases have appeared. 

Treatment. — It is good practice to begin the treatment by a mercu- 
rial purgative ; a half-grain of calomel two or three times on the first 
day, followed by a warm-water enema. All drastic cathartics should 
be avoided, owing to the irritable state of the stomach. If the pain in 
the back and loins is very severe, one twelfth of a grain of morphine 
should be administered hypodermatically, and repeated according to 
circumstances. For the irritable stomach, there are two most efficient 
remedies, carbolic acid, and lime-water with milk — a fourth of a grain 
of carbolic acid in some mint-water every two hours, and a tablespoon- 
ful of lime-water and milk, equal parts, every two hours, so that these 
remedies will be taken in alternation every hour. Ice should be kept in 
the mouth and small pieces swallowed, but care is necessary to avoid dis- 
tention of the stomach. For the epigastric tenderness, mustard should 
be applied, and, if the patient is vigorous and the reaction sthenic, 
leeches or cups should be used. During the second stage, for the irri- 
table stomach a little dry champagne is often very serviceable, as it is 
very grateful. Hydrocyanic acid, and especially chlorodyne, may also 
act well as sedatives to the stomach. If the fever is high, the skin hot 
and mordicant, the wet pack may be used with advantage, or the body 
may be sponged over and then rubbed with some animal fat, as lard 
or suet, several times a day. The temperature may be reduced further 
by the rectal injection of a scruple of quinine, but this agent should 
not be administered by the stomach, as it will surely excite vomiting. 
For the same reason all harsh and drastic or irritating medicines 
should be avoided. The delirium and obstinate wakefulness of some 
cases require morphine and atropine (the latter in small proportion) hy- 
podermatically. When the delirium is active, the patient restless and 
difficult to control, the most efficient hypnotic and calmative is duboi- 
sine given subcutaneously (-y^^- grain) ; Aitken suggests chlorodyne. 
As digestion is almost entirely suspended, it is useless to push beef -tea 
and milk when the stomach rejects everything. The best aliment is 
milk and lime-water, half and half, given in small quantity, not to 
exceed a tablespoonful every two hours. If curds are thrown up in 
hard masses, the quantity of milk is too great. Thin barley-water to 
which some milk is added, and then diluted with lime-water, is a suita- 
ble aliment. During the stage of convalescence, the utmost circumspec- 
tion is necessary in giving aliments. The algid form of yellow fever 
requires stimulants from the beginning. In the hjemorrhagic form, 
small doses of turpentine and tincture of the chloride of iron should be 
given frequently. In the sthenic form, the wet pack, leeches, quinine, 
morphine, and duboisine, are the most appropriate remedies. In the 
typhous form, suitable aliment, wine, and the stronger stimulants are 



DENGUE. 



831 



required. Yellow-fever patients should be isolated. All of the dejec- 
tions by vomit or stool should be at once disinfected. The room and 
halls should be fumigated with sulphurous acid. All articles of cloth- 
ing and bedding about the patient should be destroyed, or put into 
boiling water and boiled before handling. Questions of quarantine are 
not included in the scope of this work. 

DENGUE. 

Definition. — Dengue * is an acute febrile disease which prevails as 
an epidemic, and is characterized by two paroxysms of fever, with an 
intermission of variable duration between them, the first paroxysm 
being accompanied by high fever and joint swellings, and an eruption, 
the second subsiding suddenly with some critical evacuation. It is 
also called " break-bone fever," " dandy fever," " neuralgic fever," etc. 

Causes. — There are close analogies between dengue and relapsing 
fever ; indeed dengue is a relapsing fever. It occurs as an epidemic, 
and attacks a large part of the population among whom it appears. 
Apparently beginning on this continent, or in the West India Islands, 
it has spread to most of the warm countries of the globe, following the 
routes of human intercourse. Rush, one of the first to give an ac- 
count of it, mentions it as occurring in Philadelphia in 1780. It is not 
generally regarded as contagious, although maintained to be by Dick- 
son,! ^'^^ some others. A peculiar condition of the atmosphere seems 
necessary, the epidemics occurring after prolonged high temperature 
(Dickson), or great heat and moisture combined (AitkenJ;). It has 
been observed in several epidemics that the attacks of dengue suc- 
ceeded to epidemics of scarlet fever, of yellow fever, and of whooping- 
cough. The disease occurs in all ages and in both sexes, but the negro 
race seems to be, although not exempt, somewhat less susceptible, 
while the mulattoes are attacked equally with whites. 

Symptoms, Course, Duration, and Termination.— There may or may 
not be a prodromal or preliminary stage. The period of incubation is 
in some instances " prodigiously brief " (Dickson), the attacks in any 
given household occurring so nearly simultaneously that all are sick 
at the same time. Toward the end of an epidemic the period which 
elapses after exposure may be lengthened to five, even to ten days. 
When the epidemic is at the maximum, the attack may follow exposure 
within a few hours and the disease occur promptly without any pre- 
liminary symptoms. When prodromes occur they consist of weariness, 
lassitude, headache, anorexia, a white tongue, and more or less general 

* The word dengue is pronounced dangay. 

\ Fennel's " Southern Medical Reports," vol. ii, p. 884, " A History of the Epidemic 
Pengue as it prevailed in Charleston in the Summer of 1850." 
± Reynolds's " System," vol. i, p. 98, American edition. 



832 



FEVERS. 



soreness of the body. Usually, however, the onset of the disease is 
sudden. The patient is taken in full health, often waked out of sleep, 
with intense headache, burning pain in the temples, backache, and 
severe aching of all the joints, including the fingers and toes. Some- 
times the initial symptom is an acute pain in the knees, ankles, and 
wrists, the patient being seized while walking. General muscular stiff- 
ness follows, so that the affected members become useless, and any 
attempt to move the joints causes severe suffering. . With the head- 
ache there is also great intolerance of light and sound. The face is 
flushed and hot ; the tongue coated ; a good deal of burning pain is 
felt in the abdomen ; there are nausea and vomiting, during which a 
quantity of bilious matter comes up, and scarcely anything is retained ; 
constipation persists ; the action of the heart is rapid, the pulse strong, 
and beating at 140 or higher in children. Sometimes also, espe- 
cially in children, there is delirium, and, in very young children, the 
onset of the disease may be marked by convulsions (Dickson). An 
exanthem of very variable character, but most frequently scarlati- 
niform, may appear, and hence the frequent confounding by the 
older authors of this disease with scarlatinal rheumatism. The 
duration of the first febrile stage is very variable, lasting from six 
hours to several days. It may cease rather suddenly with critical phe- 
nomena, or slowly by lysis. The decline of the fever is signalized by 
the disappearance of the eruption if it had existed, by the appearance 
of moisture on the skin, a profuse urinary discharge, an attack of diar- 
rhoea, the stools being dark and offensive (Aitken), and by the subsi- 
dence of the headache and joint-pains. Usually, at the termination of 
the remission, the patient is in a condition of very considerable pros- 
tration, and, although much relieved, is unable to leave his bed. In 
other cases, the relief is so great and the strength so well preserved 
that the patient insists on getting up. The remission may not occur 
at all. In those' cases the joint affection appears with, and the erup- 
tions after, the first symptoms; the fever is continuous, and lasts from 
five to ten days, when it disappears with critical phenomena. It is by 
no means improbable that a distinct remission of short duration occurs, 
but escaped the observation of practitioners unprovided with the means 
of accurate investigation. The duration of the remission or intermis- 
sion is not constant, and varies from a few hours to two or four days. 
During the period of remission there are more or less headache and 
soreness, and stiffness of the joints and muscles, notwithstanding a 
very great diminution in the severity of these symptoms ; hence it may 
be concluded that the condition of the interval is rather that of remis- 
sion than intermission. At the conclusion of this interval, whether of 
several hours' or two or four days' duration, the symptoms begin again: 
the fever rises, although not so high as during the first stage ; the 
headache, some muscular soreness, but only occasionally the swollen. 



DENGUE. 



833 



red, and painful joints, are felt again ; the tongue becomes coated 
anew, the appetite ceases, and more or less nausea, very rarely vomit^ 
ing, is experienced. The distinctive peculiarity of the second period, 
however, is the occurrence of an exanthem — erythematous, roseola- 
like, rubeolous, lichenoid, etc. Usually, beginning as an efflorescence 
on the palms of the hand and soles of the feet, it spreads thence over 
the body. It is often accompanied by intense itching. The eruption 
may be distinctly localized to particular parts of the body. The dura- 
tion of the eruption is variable, lasting from several hours to two or 
three days, and terminates by desquamation of the furfuraceous kind. 
The subsidence of the second stage is gradual, and the patients are left 
in a feeble state, requiring months for complete restoration. There 
may occur other relapses. The joints continue stiff and sore for a long 
time. It is not surprising that persons attacked with dengue should 
be much reduced. The fever, severe pains, loss of sleep, inability to 
take food, the critical evacuations, and the relapses, are sufficient to tax 
severely the vital resources of the most robust patient. It is never 
fatal in adults, and it is rarely that children die in convulsions. It is 
a disease without complications, and leaves behind no sequelae. The 
whole duration of fully developed cases is about eight days, of which 
the first stage occupies three days, the intermission two days, and 
the last stage three days or nearly so, but the period of convalescence 
may be protracted over several weeks, because of the weakness, emaci- 
ation, and lingering joint swelling and pain, and relapses may several 
times take place, still further retarding recovery. 

Treatment. — As dengue is a specific disease for which we have no 
specific remedy, it must be treated symptomatically, or in accordance 
with empirical observation. During several epidemics the use of 
emetics, carried to the point of free bilious evacuations, was followed 
by decided amelioration of all the symptoms. Next to the emetic in 
importance is an efficient but mild laxative. The substitution of more 
healthy evacuations for the greenish, tarry, offensive stools has also 
had a good effect on the progress of the disease. Anodynes are needed 
to relieve the severe pains. It is probable that salicylic acid will have 
a decided influence over the rheumatic symptoms, which are such prom- 
inent features of the malady. If salicylic acid or the salicylates fail, 
antipyretic doses of quinine should be tried. It is important to main- 
tain free action of the organs of excretion ; hence, if the pain is so 
severe as to demand the administration of morphine, the bowels should 
be kept open and the kidneys active. As the first stage terminates 
with some critical evacuation, often with a sweat, the behavior of na- 
ture may possibly be imitated and the paroxysms shortened by the 
administration of pilocarpine. The intolerable itching, so often pres- 
ent, may be allayed by sponging over the part a one per cent, solution 
of carbolic acid. The joint-pains and soreness of the muscles remain- 
55 



834 



FEVERS. 



ing during convalescence may be removed by tbe application of gal- 
vanism. Tincture of chloride of iron is the most useful chalybeate to 
be given in convalescence. To restore appetite and digestion, tincture 
of nux vomica will be found efficient, or a combination of dilute phos- 
phoric acid, pyrophosphate of iron, and strychnine may be administered. 

HEAT-STROKE AND HEAT-FEVER. 

Definition. — Under the terms insolation, coup-de-soleil, siinstroJce, 
and other synonyms, are included three distinct morbid states : acute 
meningitis, which is comparatively rare ; exhaustion from heat, which 
is common ; and true sunstroke, or thermic fever,^ or heat-fever. 

Causes. — As the name implies, this disease is due to the influence 
of excessive heat, certain other conditions being concurrent. It is not 
necessary, as is popularly understood, to expose the head to the direct 
rays of the sun. Artificial heat, and the diffused atmospheric heat, 
will, under appropriate conditions, develop the disease, yet the direct 
solar rays are more powerfully causative. The habitual consumption 
of spirits, beer, and alcoholic beverages, unquestionably predisposes to 
attacks. Excessive fatigue, overcrowding, heavy and close-fitting gar- 
ments, are also influential factors. 

Pathological Anatomy. — The action of the cause is so sudden, and 
the disease is so rapid in its course, that time is not afforded for the 
development of structural changes ; nevertheless, there are character- 
istic appearances. The veins and sinuses of the brain are gorged with 
blood. ; much venous stasis exists in the lungs ; the right cavities of 
the heart are distended, and the left are contracted and empty. The 
condition of the heart is disputed. It is generally said to be flaccid, 
but, according to Wood,f it is firmly contracted immediately after 
dying, but becomes relaxed as putrefactive changes come on. The 
blood is fluid, dark, sometimes grumous, feebly alkaline, neutral and 
even acid in reaction. The red corpuscles appear to undergo in some 
cases the change known as crenatio7i.\ Post-mortem rigidity sets in 
at once and is very great. 

Symptoms. — The acute meningitis caused by heat is the same as 
that due to other causes, and, as it has been described elsewhere, need 
not be taken up again. The condition of exhaustion produced by heat 
has been observed on a large scale by the author, § and, as it is often 

* "Thermic Fever, or Sunstroke," by 11. C.Wood, Jr., M. D. Philadelphia: J. B. 
Lippincott & Co., 1872. Boylston Prize Essay, p. 34. f Ibid. 

X Dr. Levick, "Pennsylvania Hospital Reports," 1868, p. 3*73. 

§ The author in 1857 accompanied an infantry regiment, about eight hundred men, on 
the march to Utah from Fort Leavenworth on the Missouri River. The command started 
on the 18th of July ; the heat was great, and large numbers of men fell out exhausted on 
the first few days. The drinking, dissipated men were the victims almost exclusively. 
There were no deaths from this cause. 



HEAT-FEVER. 



835 



confounded witli the true coiip-cJe-soleil, should receive some considera- 
tion. During the course of some exhausting labor under a hot sun, as 
marching equipped with blankets and accoutrements, there comes on 
an increasing sense of weakness ; presently the sight grows dim, a 
rushing noise sounds in the ears, and the individual falls suddenly or 
sinks down, partially or entirely unconscious. In the most severe 
cases the man falls suddenly, or stumbles once and then falls uncon- 
scious ; a shudder or tremor passes over the body, and sometimes a 
general convulsion occurs as in the syncope from loss of blood. The 
face is pale, the features are sunken, the pupil is dilated, the surface of 
the body is cool and perspiring, the muscles are relaxed, the pulse is 
feeble and quick, and the respirations are hurried and shallow. The 
senses are obtunded, the perceptions dull and confused, or the con- 
sciousness is wholly lost. Under rest and appropriate treatment the 
symptoms subside in a few hours, and recovery is effected in twenty- 
four hours. 

The attacks of sunstroke are often preceded by prodromic symp- 
toms. The patient experiences frontal tension, headache, and vertigo, 
and is weak ; a strong sense of oppression is felt at the prascordia, and 
there may be nausea and vomiting. When the attack occurs, the pa- 
tient may pass suddenly or more slowly into a condition of uncon- 
sciousness. Notwithstanding the existence of headache, vertigo, and 
nausea, the laboring man continues at work, and suddenly falls and 
quickly becomes unconscious. A soldier on the march, or standing at 
" attention," may undergo the same experience. Another man, feeling 
the same prodromal symptoms, may be in a position to lie down, and 
hence, when apparently asleep, passes into unconsciousness. In still 
other cases the condition of unconsciousness is preceded by delirious 
acts ; the patient tries to escape from, or takes, up arms against, an 
imaginary enemy ; or the onset is announced by a peal of wild laugh- 
ter. Very often there is present an intense desire to micturate. In 
some fulminant cases, when insensibility occurs, the patient gasps a 
few times, a shudder runs over the body, and the heart stops. These 
have been called the cardiac variety of sunstroke (Morehead). In 
such cases, owing to the sudden death by syncope, there is no time for 
the development of the symptoms pertaining to the period of. uncon- 
sciousness. Usually, these symptoms are present, and are about as 
follows : The face is flushed, deeply suffused, or cyanosed, and the 
whole surface presents the same appearance ; the conjunctivae are in- 
jected ; the pupils most frequently contracted, but may be dilated or 
normal ; the breathing is rapid, noisy, and shallow, or it is labored and 
stertorous ; the pulse is very quick and bounding, or it is feeble and 
quick ; the skin is dry and hot, really mordicant, and the tempera- 
ture of the axilla ranges from 105° to 110° Fahr., most frequently at 
108° or 109°. In most cases, there is a condition of complete muscu- 



836 



FEVERS. 



lar resolution, and no movements of any kind take place, all of the 
reflexes being abolished. In a smaller number, suhsultiis tendhium is 
present, or restlessness and agitation, or there are clonic convulsions 
with tetanic rigidity, or epileptiform seizures. In a few cases, pete- 
chise appear, or haemorrhages from the mucous surfaces. Involuntary 
discharge of fajces is the rule. 

Course, Duration, and Termination. — The cases of exhaustion from 
heat usually terminate in health after twenty-four hours, under repose 
and proper treatment. The prodromal stage of heat-fever lasts a few 
hours. The fulminant form may end fatally within a few minutes. 
The ordinary form continues from half an hour to five or six hours. 
The mode of dying in the fulminant cases is at the heart ; of the ordi- 
nary form, at the lungs. Those attended with convulsions usually 
die at the head. In the cases going on to a fatal termination the tem- 
perature rises, the action of the heart becomes more rapid and feeble, 
the conjunctivae are more injected, the cyanosis deepens, the extremi- 
ties grow more livid, and the muscular resolution increases in depth. 
When recovery is about to occur, the surface becomes cooler and is 
less cyanosed ; the respiration deepens, the pulse declines in number 
and gains in volume, the reflexes are restored, restlessness rej^laces 
relaxation, and the convulsive phenomena disappear, if they have 
occurred. The mortality varies under the varying conditions of the 
attacks. It is greatest in the old, and in those with damaged heart, 
and in the obese. The mortality rates as given are vitiated by con- 
founding heat-exhaustion with heat-fever. The mortality may be 
stated at from ten to fifty per cent. ; the latter, however, is nearer the 
truth in respect to heat-fever. The cause of death being the disor- 
ganization of the blood produced by the hyperpyrexia, the failure may 
occur at the respiratory center, at the cardiac ganglia, or at the lungs. 

Diagnosis. — The most important question is the distinction between 
heat-exhaustion and heat-fever, for on this rest the indications for 
treatment, and success or failure will depend on the direction taken by 
our remedial measures. In heat-exhaustion, the surface is pale, cool, 
and relaxed, the temperature being rather below than above normal, 
and the insensibility is due to syncope and cerebral anaemia. In heat- 
fever the surface is suffused or cyanosed, the skin hot, the temperature 
rising into hyperpyrexia, and the insensibility is due to disorganization 
of the blood. Heat-fever is to be diagnosticated from the insensibility 
due to acute alcoholism, to opium narcosis, and to cerebral haemorrhage. 
The difficulty is great in differentiating between heat-fever and acute 
alcoholism, because so many alcoholics fall prey to sunstroke. The 
history is important. The man with sunstroke has been laboring or 
walking in the sun or heat, when attacked, and he has had the usual 
prodromes of the seizure. The thermometer must be invoked to de- 
cide ; in the case of alcoholism, the temperature is rather below than 



HEAT-FEVER. 



837 



above normal. In the further progress of the cases they are differen- 
tiated by the gradual recovery from alcoholic insensibility and by the 
much more speedy termination of the case of heat-fever. The distinc- 
tion from opium narcosis rests on similar grounds. The minutely con- 
tracted pupil, the slow respiration, the cold surface, are the opposite 
of the rather dilated pupil, noisy and rapid respiration, and high fever 
of heat-stroke. In the insensibility of cerebral huBmorrhage, the conju- 
gate deviations of the eyes, the slow, full pulse, the labored respira- 
tion, the low temperature of the surface, and the preservation of the 
reflexes in many cases, serve to distinguish this state from heat-fever. 

Treatment. — Heat-exhaustion requires rest and stimulants. The 
head should be low, and the body recumbent. If the patient is able to 
swallow, he should at once receive an ounce or two of brandy and 
thirty minims of tincture of opium ; or, if unable to swallow, these 
remedies can be thrown into the rectum, or some whisky and ten to 
fifteen drops of tincture of digitalis can be injected subcutaneously. 
It need not be remarked, probably, that bleeding and the application 
of ice are entirely inadmissible. 

Different methods are required in the treatment of heat-fever. The 
extraordinary temperature, on the persistence of which the danger de- 
pends, must be speedily reduced. Rubbing the body with ice, the 
cold bath, the wet pack, or the cold douche, are the means most effec- 
tive for this purpose. In India the practice consists in removing the 
patient to the shade, and at once douching the whole body, stripped, 
with cold water. This speedily reduces the temperature. The ten- 
dency to subsequent elevation of temperature is best obviated by wrap- 
ping the patient in the wet sheet. Cold water may also be thrown 
into the rectum. If depression come on, some whisky or brandy may 
be given. The subcutaneous injection of quinine may also be practiced 
to reduce \he heat. In cases characterized by restlessness and convul- 
sive phenomena, morphine, hypodermatically, has been used with great 
success.* Inhalations of chloroform have been administered with equal 
success under the same circumstances. But the inhalation of chloro- 
form and the hypodermatic injection of morphine may be pushed too 
far. On the whole, the injection of morphine is the safer expedient, 
and, the facts show, is very successful in suitable cases. One fourth of 
a grain of morphine sulphate is a proper dose for a robust adult. As 
extraordinary tolerance of the remedy is often exhibited under these 
circumstances, an amount of it may be given which would prove fatal 
in health. If the convulsions subside, the breathing become more 
tranquil, and the temperature decline under the use of the injection, 
it is doing good, and may be repeated, if necessary, in a few minutes, 
but it is better to await the action of the half -grain until it is clear 
that a third dose will be necessary. The administration of morphine 
* Dr. Hutchinson, " Pennsylvania Hospital Reports," op. cit 



838 



MIASMATIC DISEASES. 



subcutaneously is not incompatible with the use of tbe cold douche, 
wet sheet, and other measures required to abate the high temperature. 
The occurrence of sudden depression of the powers of life, the patient 
passing into collapse, is an unfortunate tendency in some of the cases, 
which may be attributed to the treatment used. The practitioner 
should be on his guard, not only to obviate this tendency by the timely 
use of stimulants, but to avoid reproach. 



MIASMATIC DISEASES. 



CHOLERA. 

Definition. — Cholera is an acute infectious disease, endemic in some 
localities, epidemic elsewhere, and characterized by vomiting and purg- 
ing of a peculiar rice-water-like fluid, and a condition of collapse and 
death, or of a reaction from collapse and the development of a typhoid 
state. It is known also as epidemic cholera, Asiatic cholera, malignant 
cholera, etc. 

Causes. — The etiological factors concerned in the diffusion of chol- 
era are very complex. Is there a cholera-germ ? The facts thus far 
accumulated render it highly probable that cholera is propagated by a 
minute organism— according to Koch, a bacillus, the comma bacillus. 
Although some eminent bacteriologists refuse to accept this view, the 
weight of testimony is in its favor, and as the crucial test of cultiva- 
tion, and the production of a cognate disease in animals, is not want- 
ing, we can hardly refuse our assent, until, at least, another organism 
is finally proved to be the morbific agent. When the first epidemics 
of cholera started on their march around the world, they pursued a 
general direction from east to west, following the routes of com- 
merce, and from one great center of population to another ; but this 
course was not inevitable from the nature of the poison, and it is now 
known that the disease pursues no defined course, and, in fact, spreads 
in all directions, according to the freedom of communication. It is 
conveyed by caravans, by ships, in clothing, baggage, and other effects, 
by streams of water, by air, etc. It is not contagious, in the common 
acceptation of that term. Physicians and attendants in cholera hos- 
pitals are not more exposed than others, during the existence of the 
epidemic, unless a local source of infection occurs. The author had 
charge of the cholera hospital in Cincinnati during the epidemic of 
1866, and not only visited the wards several times daily, but made a 
number of autopsies, and on several occasions was wounded, without 



CHOLERA. 



839 



experiencing the first symptom of the disease. The assistant physicians 
and attendants were equally exempt. The dead bodies of cholera sub- 
jects apparently possess no infective property. The bacteria of de- 
composition destroy the disease-germs of cholera. The morbific ma- 
terial or germ is more certainly conveyed in the moist state, and some 
preparation or transformation must be undergone before it becomes 
active. As it leaves the person of the sick it does not appear to have 
toxic power, but acquires this subsequently. Hence cholera is not 
communicated directly from one person to another : an intermediate 
condition of preparation is necessary. Hence the importance of the 
superficial water-supply (the ground-ioater of Pettenkofer), and of cer- 
tain geological formations. The character of the soil best adapted to 
the nurture of cholera-germs, because retentive of the surface-water, 
is alluvium, light and porous, resting on an impervious clay subsoil. 
Malarial regions are generally very favorable to the growth of cholera- 
germs. When the ground-water is low, the germs are produced in 
greater abundance than when it is high. Cholera is always spread 
rapidly when the drinking-water is supplied from the surface drainage, 
and hence is rich in organic matter. The records of cholera epidemics 
are full of most striking examples of this truth. The excretions of 
cholera patients, thrown on the ground, or into superficial privy- 
vaults, quickly reach the ground-water, multiply rapidly, and soon the 
sources of water-supply, the superficial wells and streams, become con- 
taminated. Hence it is that one of the principal sources of cholera in- 
fection is the water-supply. When an epidemic influence prevails, not 
all exposed to the poison contract the disease ; great differences in the 
individual susceptibility are found to exist. The hygienic influences 
affecting the individual are highly important. Excesses in venery, in 
spirit-drinking, late hours, and an irregular life generally, bad air, and 
moral depression and fear of the disease, exercise an unfavorable influ- 
ence. Males are more apt to have cholera than females, and infants 
are less susceptible. The mortality is less among children than among 
adults, and is greatest between twenty and thirty. Although it is true 
that heat favors the spread of cholera, and that the greatest mortality 
is during the hot season, yet it does prevail during the winter ; a nota- 
ble example was afforded by the Russian epidemic of the winter of 
1830-31. The disposition to an attack of cholera seems greatest in 
the early morning. A hot, moist, and stagnant atmosphere is especially 
favorable to the development of the epidemic influence. A light rain- 
fall, followed by a warm mist, the air being still, was the condition of 
the atmosphere when the cholera assumed its most severe phase in the 
Cincinnati epidemic* An ordinary epidemic, under the circumstances 

* A " norther," -witli rain, preceded a fearful outbreak of cholera among the United 
States troops (Eighth Infantry) at Lavacca, Texas. Reported by Dr. N. S. Jarvis, 
U. S. A., Fenner's " Southern Hospital Reports," vol. i, p. 436, et seq., 1S49, 



840 



MIASMATIC DISEASES. 



of its introduction in one of our cities, is not likely to prevail longer 
than two months. July, August, and September are the months of 
greatest prevalence of the epidemic, as a rule. From the period of 
exposure and reception of the poison until the outbreak of the disease 
— the incubation — from two to four days usually elaj^se. But this is 
not a fixed and invariable period — it may extend to one or two weeks, 
but very rarely longer. Healthy persons, arriving in an infected city, 
are attacked in from three to four days. When the germs of disease 
are brought to a healthy city, about a week elapses before cases of the 
disease appear. 

Pathological Anatomy. — If death has occurred in the asphyxia, the 
stomach contains more or less of the whey-like material of the cholera- 
discharges — a material alkaline in reaction, albuminous, and full of 
cast-off epithelium. Later, or during reactionary fever, the mucous 
membrane is congested, and marked by extravasations and ecchymoses. 
The small intestines usually contain a large quantity of the whey-like 
fluid, full of epithelium. The glands of Brunner, the solitary and 
agminated patches are thickened and very prominent. The villi of the 
mucous membrane, as well as the epithelium, are stripped off, leaving 
the basement membrane for the most part bare. The solitary glands 
of the large intestine are also infiltrated and swollen. Sometimes the 
colon is the seat of a diphtheritic process, but this is a change pertain- 
ing to the fever of reaction. The spleen is small, wrinkled, and firm 
during asphyxia, but in the secondary fever it enlarges and is softer. 
The biliary passages contain a quantity of cast-off epithelium, which 
probably obstructs the outflow of bile — for usually the gall-bladder is 
well distended with a rather thick, viscid bile. The liver is more or 
less advanced in fatty degeneration, but is not conspicuously altered, 
although, by reason of changes in the hepatic cells in spots, the organ 
may present a somewhat mottled, yellowish discoloration, mixed with 
brown. The changes in the kidneys are of the same nature as 
those of other mucous surfaces. The epithelium of the tubules is 
granular, cloudy, and is detached from the basement membrane, block- 
ing the tubes, so that the whole organ has the appearance of the 
pale, smooth, white kidney. Here and there, however, there are spots 
of injection, and occasional patches of ecchymosis. The bladder is 
empty and contracted, or contains a very little milky urine. The peri- 
toneum is dry, sticky, from the presence of a quantity of loose epithe- 
lium still adherent, and hence the membrane does not present the 
transparent and glistening appearance of health. The pleura presents 
the same conditions : its transparency is impaired, it is adhesive, and 
the epithelium is cast off in great quantity. The lungs are deeply con- 
gested, especially posteriorly ; ecchymoses of the bronchial mucous 
membrane and infarctions of the lungs are occasionally encountered. 
The great venous trunks and the right cavities of the heart are dis- 



CHOLERA. 



84:1 



tended with blood, while the left cavities are empty and contracted. 
The blood is dark, almost black in color, thick and viscid, feebly coag- 
ulable, and sometimes incoagulable. The pericardium is dry, and 
there are numerous ecchymoses on the visceral layer. The muscular 
tissue of the heart is not affected. There are but few changes in the 
brain. The author observed, in all of his autopsies, considerable hy- 
per^emia and dilatation of the vessels of the medulla oblongata. The 
constancy of this lesion would seem to indicate a relationship between 
congestion of the medulla and the cramp. 

Symptoms. — First or Prodromal Stage. — As there are two forms 
of disease from which cholera may proceed, although they are quite 
independent affections under other circumstances, they may be with 
propriety regarded as modes of manifestation of cholera-poisoning. 
These maladies are diarrhoea and cholerine. During every epidemic 
of cholera, a large proportion of cases set in by a diarrhoea, which if 
permitted to continue will develop into a typical attack of cholera. 
Others begin as a cholerine, with vomiting and purging like an ordi- 
nary cholera morbus, and if uncontrolled the case assumes the charac- 
teristics of cholera. Cholera-diarrhoea may arise from ordinary causes 
— from taking cold, errors of diet, etc. There is some chilliness, 
thirst is exacting, the tongue is pasty, and there is a bitter or mawkish 
taste. Some pain may be felt in the abdomen, but the stools pass 
with ease, are copious and watery, and cause a decided feeling of 
weakness. There may be no more than two or three stools in the 
course of the day, but the failure of strength is remarkable and quite 
out of proportion to the loss of material. Such a diarrhoea may in a 
day or two become very profuse, the stools whey-like, cramps in the 
legs, cold tongue, cold breath, toneless voice, suppression of urine 
come on, and the patient pass into cholera asphyxia. During a cholera 
epidemic there is danger that every case of diarrhoea may assume 
cholera characteristics. It has usually been observed that during a 
cholera epidemic there is a general prevalence of diarrhoea, or such a 
state of relaxation of the bowels that a laxative causes drastic effects. 
Cholerine behaves as an ordinary attack of cholera morbus, except 
that the discharges have less and less of the stomachal and fecal 
characters, that cramps are more apt to occur, and that the symp- 
toms of cholera asphyxia readily come on. In many epidemics pro- 
dromes have been observed. The author has seen, in most cases, 
mental depression, fatigue of body, and chilliness precede the regular 
attack. On the other hand, a feeling of recklessness, or apathy and 
indifference, has been noticed. In all cases diarrhoea or cholerine has 
ushered in the attack. The characteristics of the diarrhoea have been 
copious, watery, rapidly becoming whey-like stools, passed easily, with 
force, and without pain. A majority of patients are attacked after 
midnight and toward morning. If there had been no diarrhoea the 



842 



MIASMATIC DISEASES. 



day before, which is rather exceptional, the patient is waked with an 
urgent desire to go to stool, and he at once passes an ordinary diar- 
rhcea stool of great volume, and the first is quickly followed by others, 
even more copious and assuming a lighter color. If diarrhoea has 
existed during the previous day, the first stool is of a whitish color. 

Second Stage. — With the large evacuations which announce the 
onset of the regular cholera attack, there is a marked degree of chilli- 
ness, anxiety, and alarm, but with many an absolute indifference. The 
evacuations come with a rushing force and amount to quarts of gray- 
ish, or whitish, rice-water or whey-like fluid. The patient feels cold, 
weak, and dizzy, and is glad to throw himself on the bed after one or 
two of these evacuations. It is not long before vomiting sets in, if 
the attack did not begin as a cholerine. In an hour or so the stom- 
ach becomes uneasy and vomiting begins — first, the contents of the 
stomach and some bilious matter, and then the peculiar rice-water dis- 
charges — an alkaline fluid containing flocculi, which subsiding are 
found to be composed of epithelium, ammoniaco-magnesian phosphate, 
blood-corpuscles, bacteria, and various minute organisms. Sometimes 
the quantity of blood-corpuscles present is sufiicient to give the whey- 
like fluid, vomited and purged, a distinctly reddish hue. In every 
epidemic there are cases sinking rapidly without vomiting or purging, 
all the other phenomena being present. These are called cholera sicca, 
but incorrectly so, since in the intestines after death are found in 
great quantity the characteristic discharges. The vomiting is generally 
less frequent than the purging, and the quantity thrown up less. The 
vomit is thrown up with force and ejected a great distance. There is 
intense thirst, and great draughts of water are swallowed, to be quick- 
ly returned. The tongue is white, pasty, and cold. The countenance 
shrinks, has a leaden hue, and the eyes are staring, the nose pinched, 
and the breath cool. A good deal of prsecordial anxiety is felt and 
breathing is oppressed, even difficult, the respiration sighing, or a 
troublesome hiccough comes on. Very soon cramps are felt in the 
calves of the legs, and although they occur in the arms, hands, masse- 
ters, muscles of the back and abdomen in many cases, they are 
more severe in the calves than elsewhere. The temperature rapidly 
falls. At first the pulse is a little accelerated, but it soon declines 
in volume and force, becoming extremely small, barely perceptible, or 
ceases at the wrist, while the action of the heart can hardly be recog- 
nized. The surface gets cold and is covered with a sticky perspira- 
tion ; the skin loses its elasticity and wrinkles, so that the hands have 
the sodden look known as the " washerwoman's hands " ; the fingers, 
the face, and the nose and lips especially, are blue as well as cold ; 
the eyes are sunken and are surrounded by livid, almost black rings ; 
the tongue is now like ice and the breath is cold ; the voice is weak, 
husky, and sepulchral, and the urine is suppressed entirely, or dimin- 



CHOLEEA. 



843 



ished to a few drops, which is often found to be albuminous. The 
temperature of the body descends to the level of the surrounding 
media — to 96°, 92°, even 80° sometimes. The minimum, according to 
the author's observation, was 92° Fahr. Such is the algid stage of 
cholera, or cholera asphyxia. It is a remarkable circumstance that 
patients reduced to this low point, collapsed and barely living, the 
blood thick and hardly in motion, should yet preserve their faculties, 
and, when roused, return correct replies to the queries addressed them. 
The termination of this state is usually in death, but reaction may be 
established, introducing the third stage. 

Death rarely occurs in less than twelve hours from the beginning 
of symptoms. The state of collapse may last from twelve to forty- 
eight hours and even then recovery ensue, but, of course, recovery is 
exceptional under such circumstances. Again, death may occur in 
three or four hours. When reaction takes place, the pulse returns at 
the wrist slowly, and at first doubtfully, the surface very gradually 
becomes warmer, the countenance assumes a more natural appearance 
and the cheeks acquire a faint flush, the tongue is less cold, there is 
less thirst, the respirations are deeper and easy, and the temperature 
rises. The vomiting and purging lessen materially, or cease altogether, 
but, as vomiting and purging cease in the final collapse, this latter con- 
dition should not be mistaken for the former. The secretion of urine 
and the substitution of normal fseces for the rice-water discharges, 
above all other symptoms, announce the beginning of convalescence. 
If albumen be present, as is usual, it gradually diminishes and disap- 
pears in three or four days. The return to health may occupy a few 
days only, but more frequently a week or more will be required. The 
reaction may not be complete. The stomach continues irritable, thirst 
is incessant, and indulgence in drinking speedily excites vomiting. The 
tongue continues coated, or peels off, leaving a dry and glazed surface. 
The epigastrium remains tender, and the blandest food excites pain 
and is apt to be rejected. The bowels do not act well. The stools are 
rather grayish and mixed with bilious-looking matters without having 
the appearance and odor of fseces. The urinary secretion increases in 
amount, but there is considerable albumen present. There is also 
much headache, and, while a condition of somnolence is tolerably con- 
stant, there is little genuine sleep, and the mind is clouded with illu- 
sions and hallucinations. This imperfect reaction may terminate in 
recovery, which is by no means frequent, or some acute, intercurrent 
disease may arise, or the patient may lapse into cholera typhoid. The 
reaction may pass beyond normal, and convalescence be delayed by 
fever, by continued irritability of the stomach, and irregularity of the 
bowels. The eyes are watery, the cheeks flushed, and the face is spot- 
ted ; more or less headache, tinnitus aurium, and wakefulness is ex- 
perienced. After some hours, or a day or two, these symptoms may 



844: 



MIASMATIC DISEASES. 



subside and convalescence be established, or they may pass on into the 
cholera typhoid. Under this designation of cholera typhoid is meant 
a typhoid state compounded of reactionary fever and uraemia. When 
health is restored, the albumen disappears in three or four days, but in 
protracted convalescence the albumen persists, varying in amount from 
traces to ten per cent. When the state of cholera typhoid is developed, 
a condition of great debility ensues ; there are severe headache, deeply 
injected conjunctivae, vertigo, and stupor. They lie in a condition of 
somnolence, muttering unintelligibly. The tongue is coated, sordes 
accumulate about the teeth ; there are thirst, nausea, sometimes vomit- 
ing ; the abdomen is distended, and gurgling can be induced by pressure 
over the ileo-caecal valve ; there is diarrhoea, the stools being greenish 
and liquid, or constipated, or these states may alternate. Eruptions, 
sometimes like roseola or like urticaria, or erythematous, appear on 
the hands, and spread thence over the body. Cramps are apt to occur, 
and there may be convulsions in children. In the fatal cases, stupor 
deepens into coma, the pulse fails, the discharges are involuntary, and 
death occurs in collapse. On the other hand, should recovery take 
place, the stupor and hebetude of mind clear up, the albumen disap- 
pears from the urine, the vomiting ceases, some appetite returns, and 
digestion is slowly resumed. So damaged have been the organs of 
digestion, and lowered the composition of the blood, that convales- 
cence is tedious, some weeks being consumed in the work of restora- 
tion. Convalescence is often complicated by bed-sores, boils, or car- 
buncles, by diphtheritic exudation of the fauces or larynx, by bron- 
chitis, pneumonia, parotiditis, etc. 

Course, Duration, and Termination— The course of cholera is quite 
varied : it includes a period of incubation, a prodromic stage, the first 
stage, or invasion ; the second stage, or algid stage ; the third stage, 
or reaction ; and the fourth stage, or convalescence. The period of 
incubation is irregular, and varies from one day to a week. The pro- 
dromic period lasts from a few hours to a day or two. The average 
duration of fatal cases is about sixty hours, and of cases that recover, 
about nine days. Death does not often occur within the first twelve 
hours, but in the algid condition. The usual duration of the typhoid 
stage is from two to nine days, but the stage of reaction, which pre- 
cedes the typhoid, may inaugurate speedy convalescence, and terminate 
by the fifth or sixth day. The mortality from cholera in all countries 
is singularly uniform, the average of various epidemics being about 
fifty per cent. In some epidemics the mortality is as high as eighty 
per cent. ; in others, as low as twenty or thirty per cent. The last 
epidemic in this country was much less formidable, and the disease 
seemed milder than former ones. In fact, each visitation since the 
first in 1832 has manifested less virulence than the preceding one. 
The cholera-germ seems to be naturalized to the Mississippi Valley, 



CHOLERA. 



845 



for every year since the last great epidemic numerous cases occurred in 
all respects like those during the spread of epidemics. The mortality 
is generally greater at the beginning of an epidemic than at its close. 
Of the large number brought under the cholera influence during an 
epidemic prevalence of the disease, but few comparatively are attacked. 
In many the germs received into the intestines excite no disturbance ; 
in others, there is produced merely a cholera-diarrhoea ; in still others, 
a fully developed cholera-seizure follows. The prognosis is influenced 
by age, habits of life, and hygienic surroundings. Infancy, old age, 
a debilitated constitution, evil habits, especially alcoholic excess, and 
living amid the most active sources of infection, greatly increase the 
danger of an attack. In an attack of cholera the prognosis must rest 
on the condition of the individual at the time of the seizure, and on the 
severity of the attack, the prompt development of the algid state being 
especially of evil import. The signs of evil import during the stage 
of reaction are imperfect reaction, confusion of mind, suppression of 
urine, and involuntary discharges. If reaction is well established, and 
instead of convalescence cholera typhoid comes on, the condition must 
be regarded as unfavorable, although recovery is not impossible. 

Treatment. — It is important to recognize diarrhoea and cholerine 
as portions of the morbid complexus. No case of diarrhoea is unde- 
serving of attention during the existence of a cholera influence. The 
great remedy is opium ; its importance is testified to by the fact that 
this agent, in some form, enters into all the cholera remedies, secret 
and published. As the cholera-discharges are distinctly alkaline, and 
as inward osmosis can only be properly set up by the administration 
of an acid, this physical fact should be recognized in the prescrip- 
tions. Experience is in accord with theory in respect to the value of 
an acid. The following combinations for the cholera-diarrhoea the 
author has found very effective: Ijt. Acid, sulphuric, aromat., tinct. 
opii deodorat., aa | j. M. Sig. Ten to thirty drops in water every 
hour or two. Acid, sulphuric, dilut. 3 ss., tinct. opii camphorat. 

I jss. M. Sig. A teaspoonful, well diluted, every half-hour to every 
two hours. Paregoric, fortified by tincture of opium, is an efiicient 
remedy. Many prefer acetate of lead and opium in pill-form, or in 
solution. A favorite combination is spirits of chloroform, tincture 
of rhubarb, tincture of cinnamon, and tincture of opium. One of 
the most successful remedies for the preliminary diarrhoea is the 
proprietary medicine chlorodyne, which has been largely used in the 
East Indies. According to Brown-Sequard, who bases his practice on 
experience acquired in the West India Islands, cholera can certainly 
be prevented by giving sufiicient morphine in time. If the attack be- 
gin by cholerine, there is no remedy so eflicacious as the hypodermatic 
injection of morphine and atropine grain of morphine and grain 
of atropine). Indeed, it may be affirmed that the subcutaneous injection 



846 



MIASMATIC DISEASES. 



of morphine is the most efficient treatment of both forms of prelimi- 
nary disturbance and of the first stage of the attack proper. Besides 
the medicinal remedies for this stage of the disease, the utmost quiet 
must be enjoined. The food taken should consist of boiled milk, a 
soft-boiled egg, some beef or mutton broth, or a moderate quantity of 
steak or roasted beef. If the symptoms be threatening, the aliment 
should not include any solids. As thirst is excessive, the patient should 
be allowed ice ad libitum^ which he should be encouraged to swallow 
frequently in small quantities. Effervescent drinks are extremely grate- 
ful and very useful when the vomiting begins. Fermented drinks, 
as beer and champagne, are objectionable, but carbonic-acid water and 
effervescing powders are, on the other hand, very serviceable. Rec- 
ognizing the fact of the alkalinity of the discharges, we should give 
an acid reaction to the effervescing powder by increasing the relative 
proportion of acid. Mustard to the epigastrium, or a flying-blister 
will aid in the arrest of vomiting. The subcutaneous injection of mor- 
phine is still more efficient. The author must here strongly insist on 
the futility and danger of deep vesication so often practiced in cholera, 
for he has seen an inflammation of all the tissues of the abdominal 
wall, extending to the peritoneum, produced by blisters to the abdo- 
men in the algid stage. Other remedies for the vomiting are carbolic 
acid, which often acts very admirably, chlorodyne, hydrocyanic acid, 
tincture of camphor, chloroform, nitrite of amyl, chloral, etc. Of all 
the remedies for this stage, the author has had the best results from 
ther hypodermatic injection of chloral — of which a scruple may be in- 
jected every hour or two, dissolved in a sufficient quantity of water. 
It allays the cramps, and brings about reaction. It seems to act most 
efficiently when administered with morphine, or in alternation with the 
latter remedy. Good effects have followed the injection of atropine in 
the algid stage, to excite the heart to action, and to restore warmth to 
the surface. Amyl nitrite has been used by inhalation to obtain the 
same effect, and apparently with advantage. When the heart is failing 
and the surface becoming cold, there is a strong temptation to the free 
use of stimulants, and the stomach is kept full of brandy, camphor, 
ether, ammonia, and other stimulants. As these articles can not be 
absorbed, they serve to keep up vomiting. As the circulation declines, 
a little brandy will be useful, but any considerable quantity should 
not be given. Whisky can be thrown under the skin. The intrave- 
nous injection of milk has proved successful in the hands of Hodder, 
in the collapse of cholera, and the intravenous administration of salines 
has, in apparently desperate cases, brought on reaction, but which, un- 
fortunately, is not always maintained. In this direction must be looked 
for the most successful management of the algid stage of cholera in 
future epidemics. During reaction the stomach must be handled very 
cautiously, lest vomiting be excited. The digestive powers are so fee- 



DIPHTHERIA. 847 

ble that it is useless to give any food except a little hot milk or a little 
weak broth. The vomiting and diarrhoea which are so troublesome 
at this time are probably best relieved by carbolic acid and bismuth 
(5 Acid, carbolic, gr. viij, bismuthi subnitrat. 3 ij, mucil. acacite, 
aquae lauro-cerasi, aa § j. M. Sig. A teaspoonful every hour or two). 
If there are fever and headache, bromide of potassa will give relief. 
As the cholera typhoid is a condition of uraemia, efforts should be di- 
rected to restore the urinary secretion, and the treatment ought to be 
conducted according to the principles already laid down. As it is 
probable that the poison of cholera is contained in the discharges, 
these should be disinfected at once by a strong solution of the chlo- 
ride of zinc. The linen about a patient, experience has shown, is pecu- 
liarly dangerous. When the loss is not important, disinfection by 
burning should be practiced ; otherwise the material should be thrown 
into boiling water, and should not be handled until thoroughly boiled. 
Articles of clothing should be hung up in an atmosphere of sulphurous 
acid for a number of days. During the existence of an epidemic, the 
hours should be regular and all excesses avoided. The mistake made 
by changing from a full to a very restricted diet has cost many lives. 
The ordinary fruits and vegetables of the season should be taken in 
moderation. Everything indigestible should be avoided. Calmness 
favors health, while fear invites disease. Attention to the first indica- 
tions of disease may save an attack. Questions of public hygiene are 
not embraced within the scope of this work. 



DIPHTHERIA. 

Definition. — Diphtheria is an acute, specific, contagious disease, be- 
ginning by an infection of the throat, and characterized by a local exu- 
dation, and glandular enlargements, systemic poisoning, and having 
for its sequelae various paralyses. 

Causes. — As diphtheria is a communicable and an inoculable dis- 
ease, it is propagated by a specific poison, the form of which is not 
known, although suspected to exist as a minute organism. The simul- 
taneous discovery by Hueter and Oertel of a minute organism of the 
bacteria group, in the exudation, the mucous membrane, neighboring 
vessels and lymphatics, and in the- blood, at once attracted attention to 
thi^ parasite as the infecting principle. Yirchow's discovery of the 
presence of micrococci colonies in ulcerative endocarditis and elsewhere 
furnishes strong support to this theory of diphtheria. On the other 
hand, the filtration experiments of Burdon-Sanderson have cast serious 
doubts on the immediate agency of micrococci ; they seem rather to 
enact a secondary role^ but, according to either position, they are neces- 
sary to the diphtheritic process. Diphtheria prevails as an epidemic ; 
under some circumstances it is endemic, and it also occurs sporadically. 



848 



MIASMATIC DISEASES. 



Diphtheria is closely allied to scarlet fever, and it occurs during the 
course of measles, small-pox, typhus, puerperal fever, exudations de- 
veloping in the fauces during the progress of these diseases, and on the 
genitalia in the last mentioned.* Indeed, it seems well established 
that the materies morbi of these low forms of fever favor the develop- 
ment of the diphtheria-poison. While the disease occurs more or less 
throughout the whole range of civilization, it is more prevalent in the 
temperate regions. It is more apt to prevail as an epidemic during 
the winter and spring, but epidemics have occurred at all seasons. 
Like all other diseases of the same kind, all the conditions of bad hy- 
giene increase its virulence and favor its diffusion. Unquestionably, 
the chief cause of its spread is contagion. Many nurses and physicians 
have fallen victims to their devotion. " When it breaks out in a fam- 
ily, all the children are commonly affected with it, if the healthy are 
not kept apart from the sick ; and such adults as are frequently with 
them, and receive their breath near at hand, seldom escape some degree 
of the same disease." f The experience of the last century is the same 
to-day. As a rule, the more severe the case of diphtheria, the more 
intense the activity of the poison. When there are several bad cases 
in a small apartment not ventilated, the poison becomes denser and 
more virulent, and conversely, when there is a single case in a large, 
well- ventilated apartment, the poison is diluted, and its virulence less- 
ened. The young, above one year, are more susceptible than adults, 
the greatest mortality being attained from the second to the fifth year. 
Boys seem more apt to get the disease than girls, a fact which Fother^ 
gill noted in the epidemics of the middle of the last century. An acute 
catarrh of the fauces seems to invite the contagion, and although one 
attack does not confer an immunity against subsequent attacks, a con- 
siderable interval occurs between them. When we hear of children 
having diphtheria every year, we have a right to assume that errors of 
diagnosis have been committed. The poison of diphtheria exists in 
the exudations and secretions of the fauces, and it is chiefly by means 
of this that the disease is communicated. Those engaged in swabbing 
the throat receive this matter as it is ejected in coughing, or with the 
exhaled breath. Several physicians have been poisoned by blowing 
through a trachea canula. Articles of clothing may contain particles 
of matter for a long time adherent to them. Doubtless the poison 
floats in the atmosphere at a considerable distance from the original 
source. It adheres with considerable tenacity to the walls, floors, bed- 
stead, and articles of furniture, but especially to bedding, carpets, cur- 
tains, and woolen goods of all kinds. Not all who come in contact 
with the germ or poison have diphtheria, for individual susceptibility 
* Virchow's "Archiv," Bd. ix, s. 228, 1856. 

f " An Account of the Putrid Sore Throat," by John Fothergill, M. D., fifth edition, 
London, 1769, p. 31. 



DIPHTHERIA. 



849 



and predisposition are important factors. "When the predisposition 
exists, and exposure is effected, a certain interval elapses before there 
are any objective signs of the disease. This period of incubation is 
very variable, and the variations are due to the differences in the in- 
tensity of the poison and the systemic state of those poisoned. The 
more malignant the disease and the more depraved the bodily condi- 
tion, the more quickly will the symptoms of the disease appear after 
reception of the disease-germs. If the poison come in contact with an 
abraded surface, it secures immediate admission to the blood, and then 
the stage of incubation may not exceed two days. Admitted to the sys- 
tem in the ordinary way, the period of incubation will vary from three 
to ten days. By Oertel it is placed at two to five days. According to 
the author's observations, the period of incubation during the epidemic 
prevalence of the disease is in the largest number of cases three days. 

Pathological Anatomy. — Except for the nicer pathological distinc- 
tions of modern methods, we might adopt the description of Fother- 
gill* as an account suitable for to-day of the lesions of diphtheria. 
The first change consists in hypersemia — a vivid injection of the mu- 
cous membrane of the fauces. At the end of twenty-four hours a 
faint, grayish-white pellicle appears on the surface of the soft palate, 
the pillars of the fauces, the pendulum, or the tonsils. The patches 
may be no larger than pin-heads, and scarcely thick enough to prevent 
the membrane showing through them. In a few hours they greatly 
increase in number, coalesce over spaces having the area of three or 
four lines, and thicken, so that they appear like bits of curds on the 
surface of the membrane. Kow there appear, constituting the exudation 
and piercing the mucous membrane, forcing apart the epithelial cells, 
great numbers of round bodies, highly refracting single cells with thick 
walls — the micrococci. Masses of them, united in bundles and colo- 
nies, form distinct nodules, projecting above and making their way 
into the deepest part of the mucous membrane.f Leucocytes — pus- 
corpuscles — soon appear, but not in great numbers, in the deep layers 
of the mucous membrane, and they are coated by micrococci, and these 
bodies have also penetrated their interior ; but, as the process extends, 
pus-cells increase in number and spread out through the basement 
membrane and through the epithelial cells surrounding the micrococci 
colonies on all sides. Among the pus-corpuscles now appear young 
cells three or four times larger than the former, and they multiply in 
large numbers — their nuclei surrounded by a thin layer of protoplasm, 
accumulating also. Thus is formed a mass composed of micrococci, 
pus-cells, and newly formed cellular elements, which constitute a mem- 

* Fothergill did not, as Bretonneau points out, properly distinguish the diphtheritic 
sore-throat of scarlet fever from diphtheria. 

f Dr. L. Letzerich, " Beitrage zur Kenntniss der Diphtheritis," Yirchow's "Archiv," 
Band xlvi und xlvii, 1869. 
56 



850 



MIASMATIC DISEASES. 



branous patch that may be lifted off the surface.* In the croupous 
form a quantity of fibrin is exuded when the local process has reached 
the development above described. This fibrin is poured out into the 
epithelium, and between the epithelium and the basement membrane or 
" sub-epithelial tissue." The epithelial cells rapidly undergo necrosis ; 
a network of fibrin develops between them, and colonies of micrococci 
form in the outer layer of the false membrane. Succeeding exudations 
lift up the first-formed false membrane, and between them capillary 
hyemorrhages may take place, and thus the extravasated blood is inclosed 
in the meshes of the fibrinous exudation. Meanwhile the micrococci 
penetrate deeper, new deposits of fibrin occur, and hence the false mem- 
brane increases in all directions and new ones are formed. The mem- 
brane is detached and cast off by a cessation of the fibrin exudation and 
an abundant formation of pus elements. The micrococci penetrate to 
the lymphatics and lymph-canals, unless cut off from penetrating below 
by the abundance of the fibrinous exudation. The mucous membrane 
of the nose,. larynx, and air-passages, undergoes similar changes in the 
process of formation of a false membrane. When recovery takes place 
the fibrin exudations cease, and the false membrane is broken up and 
detached by the abundant formation of merely purulent cells. The 
epithelium destroyed is restored by the formation of new cells pro- 
duced from the sub-epithelial layer. In the septic form the masses of 
false membrane iindergo decomposition, bacteria form in immense 
numbers, and the micrococci penetrate to the deepest part of the mu- 
cosa, filling in the sub-epithelial and sub-mucous tissues. It is gener- 
ally conceded that the diphtheritic process as it occurs in the nose is 
more apt to produce septic infection. Here the micrococci accumulate 
in the greatest numbers, and seem possessed of the greatest activity ; 
for the periosteum, the cartilages, even the bones, are attacked. Gan- 
grene is produced in consequence of the rapid increase in cells, the 
exudations of fibrin, and the crowding of the tissues by micrococci, 
arresting the blood-supply and stopping the nutritive processes, hence 
causing a necrobiosis, which is extensive in proportion to the spread 
of the membrane formation. When this occurs, "false membrane 
mucosa, and submucosa form together one semi-liquid, discolored, 
dark pulp, or a darkish, wormwood-like, broken-down mass, or a dark, 
more firmly attached slough, from which the intense, peculiar odor of 
gangrene is spread."} 

* Burdon-Sanderson long ago described, with his usual fidelity, the fibrin, the cellular 
elements, and the transparent granules (micrococci ?) which unite to make up the false 
membrane. (" Contributions to the Pathology of Diphtheritic Sore Throat," etc., " Brit- 
ish and Foreign Medico-Chirurgical Review," January, 1860, p. 179, et seq.) 

X Jaffe, " Die Diphtheric," etc., Schmidt's " Jahrbiicher," f iinfter Artikel, vol. clviii, 
p. 73. Also, Oertcl, supra. 



DIPHTHERIA. 



851 



The lymphatics of the neck, whose vessels take their origin in the 
tissues included in the diphtheritic process, are also involved. The 
micrococci penetrate to the vasa efferentia, and are seen crowding 
these vessels in large numbers. The lymphatic glands of the part — 
submaxillary, sublingual, parotid — and the chain of cervical lymphat- 
ics underlying the sterno-cleido-mastoid are enlarged more or less ex- 
tensively. The periglandular and the general connective tissue are 
swollen, infiltrated with pus and lymphoid cells, and there may be also 
around the glands extravasations of blood. The swelling of the glands 
themselves is due to a hyperplasia of the cells, the stroma remaining 
unaffected. The membranous exudations, in a small proportion of 
cases, extends to the bronchi, but only involving a part of the tubes. 
The changes in the lungs are due to the mechanical obstruction of 
bronchi, the consequences being atelectasis, emphysema, and localized 
oedema. When the diphtheritic process invades the lung-tissue itself, 
there will be seen at various points extravasations of blood, and infarc- 
tions, and alveoli distended with cellular elements — epithelium, blood- 
corpuscles, and new cells, etc. — and micrococci colonies. In cases of 
septic infection, the muscular tissue of the heart becomes soft, is easily 
torn, and its fibrillse are far advanced in fatty degeneration, while at 
various points are extravasations of blood into the muscular substance. 
Ulcerative endocarditis, due to the development of bacterian colonies, 
thickening and vegetations of the valves, with the secondary conse- 
quences of this condition of the endocardium, have been repeatedly 
demonstrated.* The composition of the blood is much altered in the 
cases of severe toxaemia ; it is black, fluid, rather mucilaginous, and 
stains the fingers a brownish color. Important changes occur in the 
kidneys, and at a very early period of the disease. They are swollen, 
intensely hyperaemic in the severe cases, but little so in the mildest ; 
but, in all cases, changes occur in the Malpighian tufts and in the 
tubules. The tufts are hsemorrhagic, contain micrococci colonies, and 
are surrounded by lymphoid cells ; the epithelium of the tubules is 
cloudy, granular, and swollen, and is often detached in the form of 
casts with epithelium adherent. The brain is hypersemic, and there 
are numerous capillary haemorrhages, but the most interesting changes, 
which serve to explain the secondary paralyses, are those occurring in 
the spinal nerve-roots, which are thickened, while in the sheaths of the 
nerves haemorrhagic extravasations occur, and they are also filled with 
lymphoid cells and nuclei. Important changes occur in the muscles, 
beginning at any point of infection. Capillary haemorrhages f occur 

* " TJeber diphtherische Endocarditis," von C. J. Eberth in Zurich, Yirchow's " Ar- 
chiv," Band Ivii, s. 228, et seg. 

f The constant appearance of capillary haemorrhages, in various parts, referred to in the 
text, is regarded as highly characteristic. Jaff e, " Die Diphtheric," etc., Schmidt's *' Jahr- 
biicher," Band clvii, s. 73. An elaborate article, extending through five issues of the journal. 



852 



MIASMATIC DISEASES. 



in thenij and the striaB disappear in the course of a fatty and granular 
degeneration. Those muscles lying immediately under the affected 
mucous membrane are apt to undergo these changes, because invaded 
directly by the pathological products of the diphtheritic process. 

Symptoms. — There are well-marked forms of diphtheria — the catar- 
rhal, the croupous, the septicsemic, and the gangrenous. In the de- 
scription of the morbid appearances these natural divisions were kept 
in view, and all who have had any considerable experience with the 
disease will recognize the adherence to nature of these phrases. In the 
catarrhal form, the initial symptoms are those of an ordinary catarrh. 
Heat, irritation, and pain are felt in the throat, and, on the attempt to 
swallow, much soreness is experienced. Chilliness followed by some 
slight fever, headache, backache, and general muscular pains are usu- 
ally present, but in the mildest cases only some slight general malaise 
may result. In still other cases the symptoms may be more pro- 
nounced : high fever, severe sore throat, violent headache, tinnitus, 
considerable debility, nausea, and vomiting may be experienced. On 
examination of the fauces, there are seen more or less intense hyper- 
asmia, and on the palate or tonsils minute grayish- white patches, very 
thin, and firmly adherent. The tongue is covered with a thick white 
coating, which extends well forward to the tip, and is also pertina- 
ciously adherent to the organ. In a day or two, sometimes more rap- 
idly, the patches of false membrane extend over the tonsils, the pillars, 
and the pharynx by a union of numerous centers of deposit, and not 
by a marginal growth only. The thickness of this membrane is at 
this time a line or two, and it is distinctly outlined against the dark- 
red mucous membrane about it. The color of the membrane is gray- 
ish-white, but it varies from that shade to dark red, or even black. 
The reddish tint is due to extravasation of blood, and inclosure of the 
blood in the meshes of the exuded fibrin. In the catarrhal form, how- 
ever, but few cases attain to such an extent of false membrane ; there 
are a few patches which may coalesce and be limited to one side, and 
they reach their maximum by the third day, when already the mucous 
membrane has become paler, and the exudation is loosening at the 
margins. The fever which appeared at the outset has by this time 
disappeared, but in most of the cases of the catarrhal form there is no 
fever, or it ceases after the first day. The general disturbance ceases 
with the fever, except the debility, which seems in marked contrast to 
the apparent severity of the disease. Soreness of the throat, pain in 
swallowing, and some tumefaction of the submaxillary and deep cer- 
vical glands continue up to the detachment of the false membrane, 
which may take place about the sixth day. When the false mem- 
brane is detached, the mucous membrane appears red and still swollen, 
but its continuity is restored by the production of new epithelium. In 
the more severe cases the detachment of the false membrane is not 



DIPHTHERIA. 



853 



effected until some days later, the debility is considerable, and conva- 
lescence requires several days longer. The mildest cases of the catar- 
rhal form may be followed by diphtheritic paralyses and other sequelae. 

Croupous Form. — This form may begin as the ordinary catarrhal 
variety, and continues to the formation of the false membrane, with- 
out any indications of a departure from the usual course, until the 
fourth or fifth day, when it takes on a new character by the sudden 
development of a high fever, increased tumefaction of the glands, 
spreading of the false membrane, etc. "When the case from the be- 
ginning assumes the severity belonging to the croupous form, it sets 
in with violent symptoms — with chilliness but not a chill, followed by 
high fever ; or the fever begins at once with the onset of other symp- 
toms, the temperature rising to 103°, 104°, or 105° Fahr. The usual 
symptoms of the feverish state are also present — headache, general 
pains, thirst, and restlessness at night, occasionally delirium. Then 
occur the special symptoms referable to the throat — a sense of heat 
and burning, and severe pain in the act of swallowing. The sublingual 
and submaxillary glands are swollen, and especially the deep cervical 
lymphatics lying under the sterno-cleido-mastoid, which are not en- 
larged in other affections of the throat. The swollen glands are 
hard and tender, and the infiltrated connective tissue about them is 
also sensitive to pressure. The mucous membrane is intensely hy- 
percemic in parts, especially on the pendulum, the palate, the pillars of 
the fauces, and the tonsils, and it is swollen and oedematous. On this 
dark-red ground appears, in a few hours, the false membrane in small 
patches of grayish-white, and, in the course of the next twenty-four 
hours it has developed into a thick, yellowish-gray membrane, which, 
becoming drier and darker, presents an appearance not unlike the rind 
of bacon. In the course of subsequent changes the false membrane 
assumes a yellowish-gray shade, somewhat like sole-leather. The 
change in tints is at first due to the inclosure of blood within the 
meshes of the exuded fibrin, and afterward to the great increase of 
the pus-corpuscles. If this thick, tenacious, leather-like false mem- 
brane is now removed, the epithelium comes with it, leaving a raw, 
dark-red, bleeding surface beneath. Another false membrane may form 
on this surface, or it may undergo healing in the mode already de- 
scribed. "While the development of the local morbid process is pro- 
ceeding, the general condition may improve, the fever declining to 
near normal, the appetite returning, and strength increasing. An ar- 
rest of the local process may be effected at the end of the first or be- 
ginning of the second week, the membrane become detached, and 
convalescence be slowly established. More frequently, however, while 
this apparent improvement is taking place, the false membrane is 
spreading in all directions. Usually, when no attempt at the arrest of 
the disease is made, the fever rises higher, the difficulty in swallowing 



854 



MIASMATIC DISEASES. 



increases, and tlie patient is tormented by efforts to rid the throat of a 
tough secretion. At this period of the disease, a condition of profound 
adynamia may come on, and death ensue in collapse. Otherwise, the 
disease pursues its course, the false membrane extends, the swelling of 
the neck increases to formidable proportions, the salivary glands pour 
out a quantity of offensive saliva, and from the fauces is exhaled a 
horrible fetor which awakens suspicions of the setting in of gangrene. 
If the exudation does not extend to the larynx, the breathing, though 
heavy, is not dyspnoeic, and the voice, though muffled and nasal, is 
not toneless. The appetite is utterly gone, the stomach rather unset- 
tled, although vomiting is hot usual, and the bowels are rather consti- 
pated, but vomiting and diarrhoea may both exist, caused, it may be, 
by the swallowing of the ichorous matters produced in the throat. 
The urine is scanty and high-colored, and in the great majority of 
cases contains albumen (Squire and the quantity of urea is increased 
— at the maximum of the disease, doubled. Casts of the tubules with 
epithelium, adherent and hyaline cases, have also been observed in the 
cases of albuminuria. When the disease has reached the point in its 
development just described, slow recovery may take place, as already 
mentioned, or the disease may extend into the nares, downward into 
the larynx and trachea, or into the Eustachian tube. As there are 
some special features introduced into the symptomatology by such 
extension of the morbid process, it becomes necessary to enter into 
brief details on these points. When the membrane spreads into the 
nose, a disagreeable sense of stuffing is produced, the patient breathes 
through the mouth, epistaxis frequently occurs, and an ichorous muco- 
purulent discharge flows from the anterior nares, excoriates the upper 
lip, and on this raw surface not unfrequently a false membrane forms. 
This is a serious complication, owing to the fact that septicaemia is 
very apt to be produced, and death may be caused by profuse epistaxis. 
The false membrane may spread up the lachrymal duct, and form on 
the conjunctiva, or, obstructing the flow of tears, cause epiphora. If 
the false membrane extends into the Eustachian tube, there will occur 
ear-ache, noises in the ears, deafness, etc. Extension downward into 
the larynx may take place early in the disease — from the third to the 
sixth day — or it may not occur until the end of the second week. 
Laryngeal diphtheria is more apt to occur in young children and in 
old persons (Oertel). The formation of false membrane may begin in 
and be limited to the larynx. f The capacity of the larynx being 

* Keynolds'a " System of Medicine," article " Diphtheria," vol. i, American edition, 
by Lea. 

f *' Relation of Membranous Croup and Diphtheria," " Medico-Chirurgical Transac- 
tions," vol. lii, p. "The evidence before the committee is conclusive as to the fact 
that in epidemics of diphtheria cases do occur in which the false membrane is thus lim- 
ited .... but such cases are exceptional." 



DIPHTHERIA. 



855 



greater in adults than it is in children, the symptoms of stenosis are more 
pronounced in the latter. Progressive difficulty of breathing, a hoarse, 
then toneless voice, the characteristic " croupy cough," are the symptoms 
of laryngeal diphtheria. These cases present the clinical history of 
croup throughout, and the reader is referred to the article on that 
topic for the details . These cases do not continue very long, and 
their termination is usually fatal, although recoveries do ensue.* They 
prove fatal by spasm of the glottis, by obstruction of the bronchi, by 
pneumonia, by carbonic-acid poisoning, etc. In the rare cases termi- 
nating in recovery, the false membrane is expelled by coughing, and 
no new membrane is produced. The fever and other symptoms sub- 
side with the improvement in the local condition. 

S)eptic Form. — During the course of the catarrhal or croupous form, 
especially the latter, the products of decomposition entering the blood, 
the condition of septicaemia will be produced. The development of 
the systemic state is preceded by ichorous decomposition of the exu- 
dations and secretions of the fauces ; a foul-smelling and very irritat- 
ing fluid is discharged from the mouth ; the lips are eroded by it, and 
on the erosions grayish-white patches of false membrane form. Nu- 
merous capillary haemorrhages occur ; the blood mixing with the de- 
composing membranes gives them a blackish appearance ; and the 
whole mass, putrefying, presents a strong likeness to gangrene, but on 
removing the decomposing materials the mucous membrane beneath is 
seen to be merely hypersemic, and capable of entire restoration. The 
glands of the neck and the neighboring connective tissue swell enor- 
mously, and present a shining appearance, and are hard or doughy to 
the touch. When the blood is poisoned, the constitution sympathizes 
profoundly. The face has a sallow, earthy, and pallid hue ; the pulse 
is small, weak, compressible, and very slow ; the temperature does 
not pass above 100°, and is more frequently at 98°, even lower ; the 
appetite is gone, nausea, vomiting, and diarrhoea are usually present, 
the stools having a foul odor ; the urine is small in quantity and 
loaded with albumen ; and the strength is exhausted. Meanwhile the 
mental condition is that of apathy, the mind acting slowly but cor- 
rectly, the intelligence becoming clouded only at the last. In other 
cases, the development of the septicaemia occurring more slowly, the 
phenomena are virtually the same — the main features being exhaus- 
tion, slow and irregular pulse (40 or 50 beats to the minute) or 
becoming rapid and thready, the temperature below normal (96° or 
97° Fahr.), and weakness so great that fainting ensues on attempts 
to sit up, death usually occurring suddenly from failure of the heart. 
Recovery, it is claimed (Oertel), has been observed, but death is the 

* " The mortality from this complication is alone very great ; it has been estimated 
that one half of the fatal cases of diphtheria die from this accident " (Squire, op. cit^ 
p. 67). 



856 



MIASMATIC DISEASES. 



usual result in a day or two after the development of the septicaemia, 
and very rarely later than four or five days after. When recovery 
is to take place, the pulse gains in volume, force, and frequency, the 
temperature rises, and the local condition improves. Convalescence 
is necessarily very slow. 

Gangrenous Form. — This is an extension only of the septica^mic 
form, and should be so regarded. Gangrene attacks the infiltrated 
mucous membrane, and the exudations participate in the process. The 
affected parts turn black, and emit a horrible fetor. Before separation 
of the sloughs takes place, the blood is poisoned, and the patient rapidly 
passes into a condition of profound adynamia. Death is produced by 
thromboses, embolisms, failure of the heart, etc. 

Course, Duration, and Termination. — The course and behavior of 
diphtheria have been sufficiently detailed in the preceding pages. The 
several forms described are based on sound observation and experience, 
which must always be confirmed. The mortality of diphtheria varies 
greatly in different epidemics, and the results of sporadic cases are in- 
fluenced by numerous causes. In some epidemics nearly all have died. 
A mortality of one in three, one in seven, and one in ten, has been 
observed in various English epidemics. So great is the variety in the 
severity of epidemics and of individual cases, that no precise statement 
of mortality rates can be made. It is certainly true that no case of 
diphtheria should be regarded as trifling, for during the course of the 
simplest cases the most formidable symptoms may arise. The prog- 
nosis in any case is the graver, the more virulent the case from which 
the poison was obtained. The age and constitution of the individual 
attacked are of moment, for the mortality is much greater in young 
children, both on account of the danger of laryngeal implication and 
their feeble powers, and in those of any age who possess poor con- 
stitutions, are scrofulous, and enfeebled by bad habits and hygiene. 
The appearance of successive deposits, the occurrence of albuminuria, 
and the enlargement of the cervical lymphatics, indicate an extension 
of the disease. Extension to the larynx, as has already been pointed 
out, is in the highest degree unfavorable, and especially so in young 
subjects. Extension to the nasal passages is regarded as very unfavor- 
able, both on account of the greater danger of septic infection and 
the interference with respiration. Jacobi, of New York, who is high 
authority, maintains that the unfavorable prognosis of nasal diphtheria 
heretofore made must be modified, if proper treatment is instituted. 
Much vomiting and purging are unfavorable symptoms, and in the same 
way must bleeding be regarded. If the specific gravity of the urine 
declines, and casts and blood-corpuscles are present, the temperature 
also rising, these symptoms are unfavorable. If the temperature should 
rise after the fifth day, it is suggestive of some new development, or of 
an extension of the exudation. A low temperature, below normal, a 



DIPHTHERIA. 



857 



cold and clammy skin, and a slow and irregular pulse, are of particularly 
evil import. Cases that are apparently doing well sometimes termi- 
nate very unexpectedly and suddenly by paralysis of the heart. As 
regards the different forms of diphtheria, the catarrhal is the most 
hopeful ; next the croupous, and lastly the gangrenous. A majority 
of the catarrhal end in recovery — of the croupous in death. 

Sequelae. — Although the paralyses of diphtheria are really modes of 
manifestation of the poison, and are referable to changes ' occurring in 
nerve and muscle, it will be most convenient to study, together, those 
which occur during the existence of the other symptoms, and those 
which appear after the supposed termination of the disease. The 
latter group of paralyses come on two, three, even six weeks after 
the healing of the mucous membrane, but the former arise to com- 
plicate the case during the second week and subsequently. A nasal 
tone of voice, some difficulty in swallowing, and the regurgitation 
of liquids through the nose, are first observed. At length, complete 
inability to swallow occurs in the third or fourth week. On inspection, 
the palate is seen to hang limp and lifeless, and no movement is pro- 
duced by irritation, the sensibility — as Trousseau long ago pointed 
out — being absent. The power of the heart is greatly reduced at the 
same period by extension of disease to the motor apparatus. The 
slowness of the pulse sometimes is phenomenal, the beats descending 
to 60, 50, 40, and in one case, reported by Sir William Jenner,* to 16 
per minute. Paralysis of the heart may take place quite unexpectedly, 
and without any marked change in the ordinary conditions of the cir- 
culation. Paralysis of the respiratory muscles may also occur at this 
period, and may involve the phrenics and diaphragm, as in Sir William 
Gull's f case, or the intercostals and other chest-muscles. There is, 
probably, no difference, except as to rate of development and severity, 
between the cases of diphtheritic paralysis occurring in the second 
week and those which appear as sequelae. The latter pursue a nearly 
definite course. They develop slowly but not until after healing of 
the mucous membrane, and begin in the muscles of the pharynx and 
soft palate, then involve the ocular muscles, and lastly the upper and 
lower extremities. These paralyses may follow the mildest as well as 
the more severe cases. The author saw a fatal case of diphtheritic 
paralysis of the muscles of respiration in a lady of sixty, who had been 
treated for a simple sore-throat two weeks before. Bonders | men- 
tions the same fact : " Among the cases .... there were many in 
which the angina ran its course without important symptoms, several 
in which the angina was not recognized as diphtheria," etc. The 

* " Diphtheria, its Symptoms and Treatment," p. 44. 
f London "Lancet," vol. ii, 1858, p. 5. 

X " On the Anomalies of Accommodation and Refraction of the Eye " (Sydenham 
Society edition, p. 607). 



858 



MIASMATIC DISEASES. 



earliest to appear, and tlie most usual paralysis, is that of the palatal 
muscles, causing the voice to assume a nasal tone, and impairing the 
power of deglutition, especially for liquids, which are regurgitated 
largely by the nose. Ocular troubles, consisting of dimness of vision, 
double vision, divergent and convergent strabismus, dilated pupil, dis- 
orders of accommodation, etc., are produced by paresis of the third, 
fourth, and sixth nerves. Shortly after these visual disorders have 
appeared, numbness, tingling, and pain are felt in the extremities, no- 
tably the inferior. These perverted sensations are followed by paresis 
of the muscles and awkward gait, and ultimately paralysis. The same 
conditions obtain in the upper extremities — they become paretic, then 
paralytic. The muscles are apt to waste, and they lose their irritabil- 
ity first to the faradic and finally to the galvanic current, and there is 
more or less anaesthesia of the plantar surface. Remarkable variations 
in the extent of the muscular weakness are observed from day to day 
— a group of muscles not paralyzed to-day may be so to-morrow, and 
vice versa. The muscles of the larynx are attacked not usually at the 
same time with those of the pharynx, as might be expected, but when 
there is a wider diffusion of the paralytic symptoms. It may be par- 
tial, affecting only one vocal cord, or general, affecting both cords. 
There may be coincident anaesthesia of the mucous membrane. The 
voice is hoarse, husky, or wanting ; the breathing is troubled if special 
effort is necessary ; and the anaesthesia may permit foreign bodies to 
enter "the glottis, with fatal consequences. Paralysis of the neck-mus- 
cles and of the thorax is apt to occur simultaneously, an example of 
which is reported by Sir "William Gull.* When this form of paralysis 
occurs, the head can not be supported, the respiration is shallow, and the 
least effort induces dyspnoea. If not soon relieved, the consequences are 
very serious : the blood is not decarbonized, hypostatic congestion oc- 
curs, mucus accumulates, and death happens in asphyxia. The sphinc- 
ters of the rectum and bladder are usually paralyzed with the lower 
extremities, and anaphrodisia also is produced. Fortunately, diphthe- 
ritic paralysis is very amenable to treatment, and only from five to ten 
per cent, of the cases prove fatal. A cure is usually effected in a few 
weeks, but a case of general paralysis may last a number of months. 
A fatal result is caused by suffocation — the dropping of food into the 
glottis ; by pneumonia, set up by the entrance of some foreign body 
into the lungs ; by failure of respiration ; by paralysis of the heart ; 
or by some intercurrent disease. 

Diagnosis. — The catarrhal variety of diphtheria may be confounded 
with acute follicular ulceration of the tonsils, and this mistake is doubt- 
less frequently made. The systemic condition may be much the same 
in the two diseases, but the local appearances are very different. In 
the tonsillar affection, there are usually several ulcers at the orifices of 

^ Supra. 



DIPHTHERIA. 



859 



as many follicles, depressed below the surface and containing a gray- 
ish, cheesy secretion. Pain is limited to the affected tonsil, and the 
lymphatics under the angle of the jaw are a little swollen and some- 
what tender. Both tonsils may be affected when the same conditions 
obtain on the other side. In diphtheria the exudation is on the surface 
of the membrane, is not limited to the tonsil, and is accompanied by 
swelling of the deep cervical lymphatics. The identity or non-identity 
of croup and diphtheria is still siih judiceJ^ It seems, however, defi- 
nitely established that there are cases in which a false membrane is lim- 
ited to the larynx and trachea, occurring idiopathically and in the pro- 
portion of about one to thirty during an epidemic of diphtheria. That 
a membranous laryngitis can exist quite irrespective of diphtheria is 
rendered probable by analogy : there are a membranous bronchitis 
and a membranous enteritis. The fact of its actual occurrence is ad- 
mitted by Bretonneau, except that he regards it as diphtheria of the 
larynx. Judged from the clinical standpoint, croup differs from diph- 
theria in being a local affection, not contagious ; the exudation non- 
specific and formed on the surface of the mucous membrane ; in that 
it does not cause systemic infection, and is not accompanied by albu- 
minuria. The author for these reasons adheres to the non-identity of 
croup and dijihtheria. Between scarlatinal sore-throat and diphtheria 
close analogies exist, but they may be differentiated by reference to 
these points : in scarlatina there is an intense and diffused redness of 
the whole mucous membrane — in diphtheria the redness is merely 
about the infected area ; in scarlatina the exudation is on the surface 
of both tonsils and usually also on the palate, and is soft like curds — 
in diphtheria the exudation commences at one or more spots, is attached 
to the epithelium and is of a grayish-yellow or brownish color ; in scar- 
latina, the symptoms are violent — convulsions, delirium, vomiting, in- 
tense fever, inaugurating the disease— in diphtheria the symptoms are 
not so severe — there are no convulsions, delirium, etc., and only mod- 
erate fever ; in scarlatina the peculiar rash appears at the end of the 
first and beginning of the second day, and which desquamates — in 
diphtheria there is no proper eruption, only transient rashes which are 
very irregular and accidental. 

Treatment. — If the theory of a local infection followed by systemic 
poisoning be adopted, the early detection and destruction of the first 
patch of false membrane is of the highest importance. Bretonneau 
acted up vigorously to the requirements of his theory, and applied 
muriatic acid to the patches as they appeared. This practice is still 
pursued by many — by the majority of physicians, probably, but in a 
modified form. Strong solutions of nitrate of silver ; the tincture of 

* The facts collected by the committee of the Medico-Chirurgical Society for their 
" Report on the Relations of Membranous Croup and Diphtheria " are very strong and 
very ably presented. ("Medico-Chirurgical Transactions," vol. Ixii, 1879.) 



860 



MIASMATIC DISEASES. 



the chloride of iron ; solution of equal parts of perchloride and gly- 
cerine ; solutions of salicylic acid, of chloral, of chlorate of potassa, of 
borax, etc., are those most usually employed. The objections to the use 
of strong caustic applications seem insurmountable. Experience has 
shown that the morbid process can not be arrested by the most prompt 
and efficient applications, for it is impossible to penetrate to all the 
parts where germs may be deposited ; injury done to the healthy mu- 
cous membrane invites the spread of the false membrane ; the de- 
struction of one layer of false membrane does not prevent the repro- 
duction of successive layers, and it is probable systemic infection takes 
place during the period of incubation. Those w^ho employ the most 
powerful applications do not present better results. Cleanliness of 
the parts, frequent removal of decomposing materials, and disinfection 
of the discharges, are of great importance for the prevention of septi- 
caemia. These observations are especially true of diphtheria of the 
nose, the mortality from this being largely due to neglect of cleanli- 
ness and disinfection. Oertel * has abandoned and condemns all the 
strong applications above mentioned, and relies on the vapor of hot 
water containing a little salt, or chlorate of potassa, as the means for 
securing cleanliness, disengagement of the false membrane, and for 
inducing suppuration. The nares should be carefully syringed out 
every three or four hours with a weak solution of chlorine, chlorate of 
potassa, carbolic acid, salicylic acid and borax, etc. The solutions must 
be very weak, and used freely and frequently. With the spray douche 
a stream of vapor can be nearly constantly kept playing on the parts. 
Various disinfectant solutions may be used in this way. The author 
has seen excellent results from the frequent application of a solution 
of lactic acid — strong enough to taste sour — by means of a mop. A 
quantity of this may be applied by a large mop to the fauces, and by 
a syringe to the nares. By what means soever the result is accom- 
plished, careful washing of the affected parts is necessary. After- 
ward there should be thoroughly dusted over the affected region 
washed sulphur, which is best accomplished by an insufflator. The 
good effects of this practice are undoubted, and the explanation is not 
far to seek. A portion of the sulphur is oxidized, and sulphurous acid 
produced. The application of lime-water by a method originating 
in domestic practice is deserving of high commendation. It consists 
essentially in the inhalation of the vapor, as it arises from the slaking 
of lime. Some pieces of freshly burned lime are put into water, and 
the vapor is directed to the throat and nose, and inhaled. Above all 
other topical applications, according to some good authorities, is the 
atomization of a maximum solution of muriate of quinine, used as often 
as possible, the spray directed into the fauces. In the case of laryngeal 



* Ziemssen's " Clycopasdia," article "Diphtheria," op. cit. 



DIPHTHERIA. 



861 



implication, an attempt should be made to dissolve tiie false membrane 
by very frequent inhalation of atomized lime-water and lactic acid. 
Emetics are also used, to effect the mechanical displacement of the 
membrane.- Those acting promptly and producing no after-depression 
are the most suitable for this purpose, as alum, subsulphate of mer- 
cury, sulphate of zinc, ipecac, but not tartar emetic. 

The treatment of the systemic condition is equally important with 
the local. There are two principal indications — to limit the spread of 
the local disease, and to prevent systemic infection. The author has em- 
ployed, with apparently great advantage, for the first object, bromide of 
ammonium (two to fifteen grains every three hours). The bromides are 
eliminated in large part by the mucous surfaces, especially of the mouth 
and throat, and thus act locally on the very source of mischief. Act- 
ing similarly, and in a high degree efficient, is iodine. In the normal 
state very decided irritation of the fauces is produced by the iodides. 
In diphtheria the author prescribes the iodide of ammonium with the 
bromide for the purpose of effecting a modification of the morbid pro- 
cess in the fauces. To prevent systemic infection it is preferable to 
administer liquor iodi compositus — one to five drops every four hours. 
Carbolic acid may be given with iodine Liq. iodi comp. 3 ij, acid, 
carbol. 3 j. M. Sig. One fourth of a drop to two drops in water 
every four hours). The most efficient of the agents to prevent sys- 
temic infection, and at the same time act as a food, is alcohol. There 
are those who maintain that alcohol is of itself sufficient, if only a 
large enough quantity can be given. From half an ounce to an ounce 
every three hours is sometimes administered to infants by the advocates 
of an exclusively alcoholic treatment. It is certainly good practice to 
commence with moderate doses of whisky or brandy at the onset of 
the disorder, and increase them as cii'cumstances demand, as the case 
progresses. It is certainly surprising to observe the large amount 
which can be taken by even the tenderest subject. That it is proving 
beneficial is shown by an improvement in the force, rhythm, and fre- 
quency of the pulse, by rise in the temperature if below, by a fall in 
the temperature if much above normal, and by a change for the better 
in the general state. Quinine is often given with alcohol for the pur- 
pose of support, and as an antipyretic when the temperature is high. 
The use of quinine by atomization has been briefly referred to. It is 
questionable whether the good effects apparently produced by this 
mode of application were due to the systemic or local action of the 
quinine, for much of that reaching the fauces is swallowed. Kot only 
stimulants and quinine, but nourishing aliments, are required in this 
disease from the beginning. Milk, beef-essence, egg-nogg, etc., must 
be given systematically, and when collapse is threatened the intervals 
between the feedings must be short. Those who have personal charge 
of a diphtheritic patient, and the physician, need to exercise great cir- 



862 



MIASMATIC DISEASES. 



cumspection to avoid infection. Several physicians have lost their 
lives by catching matter from the throat in inspecting the parts, bv 
clearing the canula used in a tracheal fistula, and by making autopsies. 
Whenever a case occurs in a family, it should be at once isolated. All 
the dejections, expectorated matters, and utensils used about the pa- 
tient should be immediately disinfected ; clothing and linens used dur- 
ing the illness should be destroyed ; and the furniture and floors should 
be washed with chloride-of-zinc solution, papering removed and de- 
stroyed, carpets disinfected by heat, etc. The author was personally 
cognizant of the following facts : A family consisting of father, mother, 
two children, and a nurse, were put into rooms of a great hotel in Sar- 
atoga that had just been vacated by a family returning home, of whom 
several were ill with some affection of the throat ; in a week the little 
boy became affected with severe diphtheria, was removed to another 
and a larger room, where he died ; and into this room some new-comers 
were put the day following the removal of the dead body, without any 
change in the bed or furniture ! How many more victims we do not 
know. The paralytic affections of diphtheria require iron and quinine, 
the phosphates, a generous diet, and a change of air. If they do not 
yield and get well under these measures, special stimulants of the nerv- 
ous system are then necessary. Strychnine should be given — hypoder- 
matically if the case is obstinate — and the muscles should be first ex- 
ercised with the galvanic current, slowly interrupted, and with the 
faradic current when the contractility of the muscle to the latter has 
been recovered. When paralysis of the muscles of respiration has oc- 
curred, prompt application of these remedies becomes necessary. The 
pneumogastric, the phrenic, and the intercostal nerves must be galvan- 
ized in turn by currents of considerable strength, and the diaphragm 
should be brought directly within the circuit by poles placed on oppo- 
site sides. The question of tracheotomy in laryngeal diphtheria is 
still suh judice. The mortality is so large after this operation, as per- 
formed in this country, only as a dernier ressort, that there is a grow- 
ing disinclination to its performance. In France it is performed earlier, 
with better results. Nevertheless, the successful issue of some ap- 
parently desperate cases, such as those of Mr. Lawson and Mr. Pugin 
Thornton, encourages further efforts in this direction.* 

OEREBRO-SPINAL MENINGITIS— CEREBRO-SPINAL FEVER. 

Definition. — Cerebrospinal fever is an acute, infectious disease, 
which prevails as an epidemic, and occurs also in the sporadic form, 

* "Transactions of the Clinical Society," vol. xii, pp. 117, 122, "Cases of Trache- 
otomy in the Last Stage of Diphtheria — Recovery." For an elaborate discussion of the 
subject, see Dr. J. Solis Cohen's work on the throat ; also, *' British Medical Journal," 
April 10, 1880. 



CEREBRO-SPINAL MENINGITIS. 



863 



and is characterized by symptoms of excitation, followed by symptoms 
of depression of the cerebro-spinal functions, by various forms of erup- 
tions on the skin and by fever of moderate grade — the symptoms being 
dependent on an inflammation of the membranes of the brain and 
spinal cord. It has received various designations — as spotted fever, 
epidemic meningitis {^iiWo), petechial fever (G. B. Wood). Cerebro- 
spiyial meyiingitis is the term most generally used, and cerebro-spinal 
fever is that proposed in the " Nomenclature of Diseases." 

Causes. — Cerebro-spinal meningitis prevails under the most opposite 
conditions of climate and soil, and at all seasons ; but certain parts of 
the globe have not as yet been visited — Asia, Australia, and Africa, 
except Algiers, having escaped.* Epidemics appear simultaneously in 
districts widely separated, under circumstances, as to soil, climate, and 
hygienical surroundings, the most diverse. While these facts are true, 
it is also evident that season has some slight influence, not directly, 
but indirectly, through the changes in habits and modes of life imposed 
by climate. The disease prevails more during the winter and spring, 
a fact which is true of the epidemics in this country and other places. 
Local conditions, good or bad hygiene, or station in life, are without 
influence in its causation. The disease selects by preference the young, 
especially young men, but no age and neither sex are exempt. Young 
recruits, the boys of a boarding-school, children, male and female, 
under fifteen, are favorite victims, while the disease becomes rapidly 
less and less frequent after twenty-five. There is probably much truth 
in Hunt's f observation that this disease " has its favored habitat in 
cold, damp, and overcrowded tenements, preferring prisons an^ bar- 
racks," as respects its appearance among troops. The author witnessed 
an epidemic among the boy inmates of a military school, most favor- 
ably situated as respects the known hygienic conditions, and there was 
no extension of the disease in the surrounding rather thickly populated 
neighborhood. " In April, 1863, four cases occurred in a single tent 
of the Twenty-second North Carolina : three of these cases died, all 
being from one family of conscripts, while the fourth tent-mate, an old 
soldier, recovered. It is difficult to define any special circumstances 
affecting this tent in preference to the others," says Dr. Robinson, 
who reports the incident. A great many examples have now been col- 
lected of outbreaks within very limited areas, as in jails, prisons, indi- 
vidual houses, confined to such areas, while simultaneously similar out- 
breaks are occurring at distant points. It is supposed that the places 
visited are in a bad hygienic state, but there must be some other ele- 
ment present, for the nurture and development of which evil hygienic 
influences are necessary. There must be a peculiar miasm^ materies 

* Lombard, " Traite de Climatologie Medicale," op. cit, vol. iv. 
f *' United States Sanitary Commission Memoirs," edited by Flint, chap. i5, on " Cere* 
bro-spinal Meningitis," by Dr, Sanford B. Hunt, p. 383. 



864: 



MIASMATIC DISEASES. 



morhi, or germ present. The nature of this unknown principle has not 
as yet been ascertained. The etiological facts thus far presented de- 
monstrate that the disease is not contagious in the proper meaning of 
the term. That it is infectious there can be no reasonable doubt. Dr. 
Burdon-Sandersan * concludes that it is not contagious ; that there were 
no instances of spread from the family first attacked ; that the disease 
appeared simultaneously in the two districts, which were thirty miles 
apart ; that in no instance were two persons attacked in one house. Dr. 
Lidell t says that " no relation by contact whatever can be traced be- 
tween them," in the cases occurring in Stanton Hospital. The general 
experience of American physicians, as collected by Stille, ^ is against 
contagion, in the sense that small-pox is contagious. 

Pathological Anatomy. — The changes wrought by this disease are 
almost as distinctive as those of typhoid fever. They are chiefly in 
the cerebro-spinal axis. The skin after death presents traces of the 
herpetic eruptions which are usually seen during life. There are ex- 
tensive suggillations, not confined to the dependent parts only, and large 
patches of ecchymoses, the body in some instances being almost black 
(Stille). The post-mortem rigidity is strongly marked, the muscles, in 
cases that have continued for many weeks, being much emaciated. 
Besides emaciation the muscles are found to have undergone granular 
degeneration to a greater or less extent. The dura mater and arach- 
noid may be but little altered, but usually present traces of hypersemia, 
the arachnoid rough and opaque also. The pia mater is always con- 
gested, often intensely punctated with capillary hiemorrhages, and 
thick and opaque by reason of interstitial exudations. After the ini- 
tial hypersemia, wandering leucocytes in great numbers are found in 
the neighborhood of the vessels, and these are the only changes seen 
in the fulminant form, because there has not been sufficient time to 
develop others. After a day or two, the subarachnoid spaces contain 
more or less cloudy serum, sometimes reddish from the presence of red 
blood-corpuscles. Next, the membrane is infiltrated by an exudation 
composed for the most part of purulent elements having a greenish or 
yellowish color ; the exudation may be more consistent, firmer, and of 
a gelatinous character. Dr. Burdon-Sanderson found that the gelati- 
nous material consisted of cells having many points of resemblance to 
but still differing from pus-corpuscles, and that the interstitial sub- 
stance was crowded with granules. The exudation may be several 
lines in thickness, and it is found in greatest abundance along the 
great vessels in the fissure of Sylvius, about the optic chiasm, infun- 

* " Official Report on the Epidemic of Cerebro-spinal Meningitis of Northern Germany,'^ 
London, 1865. 

f "American Journal of the Medical Sciences," January, 1865, p. 1, vol. xlix. 
X " Epidemic Meningitis ; or, Cerebro-spinal Meningitis," by Alfred Stille, M. D., 
Philadelphia, Lindsay & Blakiston, 1867, p. 178. 



CEREBRO-SPINAL MENINGITIS. 



865 



dibulum, pons, and cerebellum. The whole convexity of the hemi« 
spheres may be covered, but usually here the exudation is most abun- 
dant in the sulci between the convolutions. As regards the visceral 
arachnoid, which is usually more or less thickened and opaque, Klebs ^' 
has found that this change is due to purulent inhltration. Similar 
structural alterations are found in the membranes of the spinal canal. 
The dura mater sometimes presents the same character of changes as 
in recent pachymeningitis (Klebs, s. 333), at least the hsemorrhagic 
extravasation ; the arachnoid is more or less cloudy from infiltration 
with pus-cells ; but the most important of the alterations are those in 
the pia, which is strongly adherent to the cord at all points. As in the 
brain, the first morbid appearance consists in hyperaemia, and then 
serum, pus, gelatinous exudation of greater or less thickness, the nerve- 
roots entirely covered with a thick layer of exudation, follow in order 
according to the time given to them. It follows, then, that in the ful- 
minant form, death occurring in a few hours, there may be but little 
evidence in the spinal canal of the severity of the malady. The ravages 
of this disease are not limited to the membranes. The ventricles con- 
tain more or less turbid serum, the ependyma and the choroid plexus 
are hypersemic, and there may be more or less of the purulent exuda- 
tion. Those portions of the brain and spinal substance adjacent to 
the pia mater are, in advanced cases, altered by hyperaemia and by the 
imbibition of fluids, so that the nerve-elements are more or less disas- 
sociated (Klebs). In cases of long standing, the effusion may be so 
great as to cause flattening of the convolutions and oedema of the 
brain. In one case the central canal of the cord was filled with pure 
pus (Ziemssen). Besides these 2^ost-7no7'tem appearances which are ne- 
cessary to constitute the disease, various alterations have been found, 
and some of them so constantly as to justify the opinion that they are 
parts of the morbid complexus. The heart-muscle, as it is in other 
fevers, is soft, friable, and granular in the cases of some weeks' dura- 
tion, but unaltered in the fulminant form. The blood is dark, fluid, 
wanting in coagulability, and the walls of the vessels are stained by 
it. The lungs frequently present evidences of bronchitis, catarrhal 
pneumonia, atelectasis, etc. The hepatic cells and the tubular epithe- 
lium are cloudy and more or less granular by deposit of fat-granules 
(Klebs), a change which is likened to that which takes place in phos- 
phorus-poisoning. 

Symptoms. — There are marked differences in the behavior of cases 
of cerebro-spinal meningitis, but they may be comprehended in four 
groups : the ordinary or common form ; the fulminant ; the petechial ; 
and the abortive. 

The Common Form. — Almost always the disease begins abruptly, 

* " Zur Pathologie der epidemiscben Meningitis," von Dr. Klebs in Berlin, Yirchow's 
" Archiv," xxxiv, s. 32*7, et seq. 
57 



866 



MIASMATIC DISEASES. 



and if prodromes exist they are headaclie, muscular pains, vertigo, and 
fatigue, which disappear just as the disease is about to manifest 
itself.* A chill, or a decided sense of chilliness, an intolerable head- 
ache, nausea, vomiting, vertigo, and an . overwhelming sense of weak- 
ness and illness, are the formidable symptoms with which the disease 
opens. The pain in the head may be like a constricting band, especially 
about the forehead, or a boring or lancinating pain shooting in all di- 
rections, or the whole head is the seat of an intense but indescribable 
anguish. With every attempt to rise up, vertigo comes on and vomit- 
ing is induced, but when recumbent the vertigo often persists, the 
patient seizing hold of the bed to keep steady. The vomiting is 
causeless so far as the stomach is concerned ; at first food and after- 
ward some mucus and bilious matter come up. In a few hours the 
muscles of the neck become somewhat stiff, and pain is experienced 
with every attempt to turn the head. An extension of this state of 
the cervical muscles takes place to the muscles of the spinal column, 
which become stiff, rigid, and painful with all attempts to move the 
body. The muscles of both upper and lower extremities are affected 
in the same way, and the motions of flexion and extension are both 
painful and awkwardly performed. At the same time symptoms of 
irritation of sensory nerves are experienced. The surface of the body 
generally is highly sensitive, but the skin of the temples, neck and face 
is especially so, a light pinch causing expression of suffering even 
when insensibility is profound. Headache is, however, the source of 
greatest suffering, which is manifest by restlessness and groaning 
during the existence of more or less complete insensibility. At the 
outset high mental excitement introduces delirium ; in children, con- 
vulsions may occur ; the delirium may be active, maniacal, the patient 
difficult of restraint, or it may assume a busy, trembling character. 
The symptoms of excitation in the mental sphere do not continue long, 
for effusion which occurs in the course of the first day causes depres- 
sion of this function, and the excitement or delirium gives place to 
somnolence or stupor. The rigidity of the neck increases, and, the 
spinal muscles also contracting, the head is drawn back and the spine 
curved ; the forearms are partly flexed on the arms, the legs on the 
thighs. In the milder cases there is a condition of somnolence, from 
which the patient may be aroused and will answer correctly in part, 
but he at once falls into stupor, or the state of somnolence is inter- 
spersed with paroxysms of active delirium. Besides the condition 
of rigidity of the muscles generally, attacks of cramp and transient 
spasms occur. Convulsions at the outset in the case of children have 
already been referred to, but the cramps and spasms here intended 

* Githens says that " there is a week of prodromata," "American Journal of Medical 
Sciences," July, 1867, "Notes of Ninety-eight Cases of Epidemic Cerebro-spinal Menin- 
gitis," etc., by W. H. H. Githens, M. D. 



CEEEBRO-SPINAL MENINGITIS. 



867 



occur in groups of muscles — cramps in the muscles of the legs chiefly, 
and spasmodic twitchings in the muscles of the lips, eyelids, etc. The 
face is usually pale and sunken, the features fixed, sometimes re- 
tracted (I'isus sardonicus), and always expressive of suffering, mani- 
fested in the deepest stupor. The special senses are more or less dis- 
ordered. Intolerance of light is succeeded by double vision, amblyopia, 
and, in some cases, amaurosis ; tinnitus aurium, vertigo, and intoler- 
ance of sounds, are succeeded by impaired hearing, in many cases by 
permanent deafness. Taste is lost, appetite is absent, and vomiting is 
frequent. Constipation exists at the first part of the disease, but 
toward the close diarrhoea and involuntary evacuations occur. The 
tongue becomes very dry and cracked ; sordes accumulate about the 
teeth, some blood exudes from the gums and nares, and the hardened 
clots block up the anterior nares and collect about the teeth. It not 
unfrequently happens that lumbrici are thrown up in vomiting. It is 
remarkable how little the circulatory system participates in the inflam- 
matory disturbance of the nervous system. The pulse is usually a 
little quickened, but it does not exceed 100 as a rule within the 
first four or five days ; but very distinctive features are the irreg- 
ularity of the pulse, the unaccountable quickening, the equally unac- 
countable slowing, and the variations in tension. The respiration is 
equally ii-regular — at first quickened, and afterward becoming variable 
in respect to the depth and rhythm. When sufficient effusion occurs to 
compress the medulla — in from three to five days — the respiration as- 
sumes the well-known Cheyne-Stokes type — is sighing and irregular. 
Various kinds of eruption appear on the body, but these are not 
observed in every epidemic, although it is our observation that some 
form of eruption will be found if careful search be made. Herpetic 
eruptions are most frequent, next roseola and urticaria — all eruptions 
belonging to the group of trophic affections, and petechias, those due 
to disintegration of the blood. The most frequent site of the herpes 
is on the face, but it may occur on any part, while the others are dis- 
tributed over the body irregularly. Having attained its maximum in 
from three to six days, the case may take either of two directions 
— to a fatal termination ; to recovery. In the fatal cases the stupor 
deepens into profound coma ; the symptoms of motor and sensory exci- 
tation yield to those of depression ; the rigidity and contraction relax ; 
the extremities become limp and paralyzed ; the paralysis may be gen- 
eral or limited to one side ; the pupils are dilated and motionless, the 
eyes deeply sunken and surrounded by a dark ring ; no noise awakens 
a reponse ; deglutition is slowly and at last not at all performed ; the 
evacuations are involuntary ; the temperature rises in some cases to 
105°, 106°, even 108°, and the pulse beats too rapidly to be counted 
In the cases taking the other direction, the symptoms of depression are 
necessarily slight and transient, for any considerable depression indi- 



868 



MIASMATIC DISEASES. 



cates an amount of damage done by the effusion such as to be incom- 
patible with recovery. In the favorable cases the rigidity of the neck 
and spine gradually subside, but do not entirely disappear for some 
time after recovery ; the vomiting ceases ; the headache subsides but 
does not entirely disappear, and the strength is slowly regained. From 
the well-marked cases, as just described, to the abortive form, there are 
numerous gradations in severity. During every epidemic, and also of 
those occurring sporadically, many of the cases are very mild. In 
such examples we observe the sudden onset, considerable headache, 
stiffness of the muscles, but little or no delirium, and no symptoms of 
depression. 

The Fulminant Form. — In this form we find the poison in its 
most active condition. The patients are struck down in the midst of 
full health, and pass in a few hours into a state of collapse. There is 
usually a severe chill ; the patient becomes cyanosed ; the skin grows 
cold, and is covered with a clammy sweat ; the face shrinks, and is 
livid ; the eyes, surrounded with black rings, sink deeply in their orbits ; 
intense pain is at first felt in the head, but in a short time conscious- 
ness is lost, preceded by brief delirium ; respiration is slow, labored, 
and sighing ; the pulse is rapid, feeble, and soon ceases at the wrist ; 
purpuric blotches appear on various parts of the body, which some- 
times quickly vesicate and slough ; the urine is scanty, and loaded with 
albumen. Such cases prove fatal in a few hours or in a few days. 
Fortunately, they have occurred less frequently in the later epidem- 
ics, and are rare, if not unknown, in the sporadic form. 

The Petechial Form. — This differs from the ordinary form, in the 
greater tendency which the cases exhibit toward dissolution of the 
blood. Bleeding takes place from the gums and nares, and extravasa- 
tions occur under the skin at various points, forming petechise and 
vibices. In the severest cases of this form, the symptoms are extreme 
from the beginning, there are great prostration, extensive purpuric 
patches, vibices, and ecchymoses, coma appears early, and a fatal re- 
sult is reached in three or four days. In the lighter cases, the only 
departure from the course of the ordinary form is the occurrence of 
numerous and extensive ecchymoses and vibices, and of haemorrhages 
from the mucous surfaces. The mortality has apparently not been the 
greater by reason of this preponderance of the purpuric spots. 

The Abortive Form consists in the occurrence of headache, stiff 
neck and spine, vomiting, without fever, in those who are much ex- 
posed to the disease, as mothers, nurses, physicians, etc., but are not 
susceptible further than this to the action of the poison. The malady 
in this abortive form does not require confinement to bed, and ceases, 
without further development, in two or three days. Writers (Ziems- 
sen) also describe an intermittent form, but there are no differences 
really between this and the ordinary form ; for the range of tempera- 



CEREBRO-SPINAL MENINGITIS. 



869 



ture is so irregular that no typical thermal line can be drawn for this 
disease. 

Course, Duration, and Termination.— None of the acute infectious 
diseases present such irregularities in their course as cerebro-spinal 
meningitis. From the course of the fulminant form to that of the 
ordinary form with the usual complications and the protracted conva- 
lescence, diversified by relapses, there is an enormous difference in 
point of duration. While the former occupies from four or five hours 
to two or three days, the latter continues four weeks, six weeks, three 
months, according to the behavior of the several stages. The severe 
cases of the ordinary form terminate in from one to two weeks. Cases 
that are very protracted usually terminate in recovery, although vari- 
ous disabilities may remain, but deaths have occurred in the sixth or 
seventh week (Radcliffe The mortality has varied greatly in dif- 
ferent epidemics, from eighty to twenty per cent. It seems to be estab- 
lished that the general mortality is declining, rather than increasing, 
although some recent statistics place it at almost the highest point. In 
a late Massachusetts epidemic the mortality was a little over sixty-one 
per cent., and in the last Philadelphia epidemic it was thirty-three per 
cent. (Stille). During the same year the mortality at Hardwicke Hos- 
pital, Dublin, was eighty per cent. (Radcliffe). The sporadic cases are 
as a rule much less severe than those during an epidemic. The sever- 
ity of the disease is increased by various complications, and the recov- 
ery hindered by sequelae. The most important of these complications 
is broncho-pneumonia and albuminuria. As regards sequel£e, every 
epidemic leaves behind sad examples of the ravages committed in the 
brain and organs of sense. One of the most usual cerebral affections 
left by the disease is chronic hydrocephalus. After the cessation of 
the inflammation, morbid products, contracting and solidifying, com- 
press the vena Galeni and the straight sinus ; the ependyma undergoes 
considerable thickening, and the fluid in the ventricles increases. Flat- 
tening of the convolutions and atrophy of the brain are the results. 
In the cases which have come under the author's notice, the head was 
large, the mind weak, the skull apparently thin, the eyes prominent, 
the extremities paretic, and the muscular acts incoordinate. Headache 
is a pretty nearly constant symptom ; but, at intervals which are, how- 
ever, not regular, paroxysms occur in which intense headache, vomit- 
ing, vertigo, and prolonged stupor with delirious intervals occur ; 
sometimes there are convulsions, unconsciousness, and involuntary 
evacuations, or there may be merely severe headache, intolerance of 
light and sound, vertigo, and vomiting. If the interval between the 
seizures is long, considerable improvement may take place in the gen- 
eral health, and expectations of recovery may be entertained. Usually 

* Dr. J. Netten Radcliffe, Reynolds's " System," article " Cerebro-spinal Meningitis," 
American edition, H. C. Lea's Son & Co., 1880. 



870 



MIASMATIC DISEASES. 



death takes place in one of tlie seizures, or the patient may be cut off 
by some intercurrent disease. Recovery very rarely ensues, if possible 
at all. Partial recovery is not uncommon — the mind being weak, the 
special senses impaired, members paralyzed and deformed. Paralysis 
of cranial nerves, hemiplegia, defects of speech, etc., are results of 
cerebro-spinal meningitis produced by the organization of the exuda- 
tion, the pseudo-membrane causing injury of parts by pressure. The 
special senses are very frequently permanently damaged. The eye is 
injured by a simultaneous suppurative inflammation, and by the ex- 
tension of the inflammation along the sheath of the optic nerve. Iritis, 
choroiditis, retinitis, opacities of the cornea, are the most important. 
The auditory nerve is readily injured, owing to its softness of texture ; 
hence we may suppose the frequency with which impaired hearing re- 
sults, but inflammation of the internal and middle ear often occurs si- 
multaneously with the inflammation of the meninges. Further, inflam- 
mation may extend by contiguity of tissue along the sheath of the 
auditory nerve. The result is that, in a large proportion of cases, dull- 
ness of hearing to deafness is found to exist after the termination of 
the disease. 

Diagnosis. — Cerebro-spinal meningitis may be confounded with 
tubercular meningitis and typhoid fever. The distinction between 
tubercular and epidemic meningitis rests on these points : the former 
is always sporadic ; is preceded by prodromic symptoms ; its course is 
marked by decided crises ; the rhythm of the pulse and respiration is 
much disturbed, and there are no eruptions. As, however, the same 
tissue is involved and by an analogous process, it need not occasion 
surprise that these diseases present very similar symptoms. The dif- 
ferentiation from typhoid rests on these points : typhoid comes on 
more slowly, is without the intense headache, the muscular rigidity, 
and the causeless vomiting of meningitis ; in typhoid there is diar- 
rhoea — in meningitis, constipation ; in typhoid there are some hebe- 
tude of mind, muttering delirium, stupor — in meningitis, active delirium 
terminating in coma, or stupor interspersed with delirium ; in typhoid 
there is a typical thermal line — in meningitis there is no regular 
course to the fever ; in typhoid the disease develops slowly to its 
maximum — in meningitis the maximum is reached in four or five days; 
in typhoid there is a characteristic rose-colored, lenticular eruption — 
in meningitis there are various kinds of eruptions, pursuing no definite 
plan. 

Treatment. — The accumulated experience of the medical profession 
seems now to indicate the superiority of opium as a remedy for cere- 
bro-spinal meningitis. The author has witnessed some striking exam- 
ples of its value, especially in the form of morphine hypodermatically. 
In Germany it holds the first place (Ziemssen). In various epidemics, 
Boudin has found opium the only remedy worthy of confidence. Stille 



CEREBRO-SPIXAL MENINGITIS. 



871 



strongly advocates its employment. There are two points in regard 
to the administration of opium, on which the author strongly insists — 
early and efficient administration. It should anticij)ate the effusion 
by an antagonistic action on the vessels. To accomplish this object, 
large doses of morphine are necessary, for, as every observer has wit- 
nessed, there are a remarkable increase of the arterial tension and slow- 
ing of the heart produced by a full dose ; and these are the conditions 
most necessary to prevent migration of the white corpuscles. Aside 
from theoretical considerations, it has been observed that there is a 
singular tolerance of opium in this disease. A decided effect should 
be produced, and the quantity necessary must be prescribed. The 
period when opium or morphine may be most useful is limited by the 
effusion ; after the first four or five days it is less important, but its 
utility does not cease until the symptoms of depression come on. 
Quinine and ergot have both been largely used in this country, with 
and without opium, but the evidence in favor of these remedies is not 
satisfactory. If there is active delirium, fluid extract of gelsemium 
(one to five drops every two to four hours) is useful in allaying excite- 
ment. When the period of depression approaches, quinine, carbonate 
of ammonia, and especially turpentine, which is more particularly in- 
dicated when the skin is relaxed and cold, are the most useful reme- 
dies. Although ice-bags and cold applications are much advised for 
the head and spine, the author holds that they do mischief by the 
depression of the circulation which they cause. He advises instead, 
the use of hot water applied by a sponge, passed over the spine 
every two or three hours. If there is constipation, a mercurial pur- 
gative may be given, but the best authorities condemn the use of 
mercury to procure absorption of the inflamed products — a bit of Eng- 
lish practice lately revived in Germany. On the other hand, iodide of 
potassium has been used with success to remove adventitious prod- 
ucts after the acute attack has subsided. The success of this mea- 
sure will be promoted by the frequent application of a hot douche to 
the spine, flying-blisters, and the passage of a weak, continuous gal- 
vanic current, but not until all local disease has wholly subsided. As 
this disease is marked by great depression of the vital powers, stimu- 
lants are needed early, but they should not be given recklessly. When 
the pulse becomes stronger and more regular under their use, they 
do good ; but, if the tongue grows dry and the delirium more excit- 
ing, they do mischief. A generous diet is required from the outset. 
Milk, eggs, beef -juice, mutton-broth, etc., should be given every three 
hours, day and night, to avoid paroxysms of weakness in the early 
morning. 



872 



MIASMATIC DISEASES. 



INFLUENZA— EPIDEMIC CATARRH. 

Definition. — Influenza is a specific epidemic disease, self-limited, 
characterized by catarrh of the respiratory organs, and sometimes of 
the digestive, and by nervous symptoms and debility. 

Causes. — Epidemics of influenza have appeared from early in the 
sixteenth century until the nineteenth. Parkes, however, traces back 
epidemics to the ninth century. The usual duration of an epidemic is 
two to four years, during which the whole habitable globe may be 
visited. An epizootic, similar in all respects to the epidemic in the 
human family, has occasionally prevailed as widely among horses. 
Influenza occurs in all climates and latitudes, and visits on its rounds 
all countries in both hemispheres ; but it may limit its ravages to one 
hemisphere, or to a single country. The rate of its progress varies : 
thus Europe has been gone over in six weeks by one epidemic — in six 
months by another. The rate of spread varies as much in particular 
countries visited, and a month has been consumed in the extension of 
the epidemic influence from London to Edinburgh (Parkes). As it 
prevails under all conditions of soil and climate, and is not contagious, 
there must be present some morbific principle in the atmosphere. 
That it is a minute organism is a theory which best explains the facts 
connected with the spread. During several epidemics it has been ob- 
served that various kinds of fungi flourished in unusual abundance. 
There is no regular period of incubation, but attacks occur immedi- 
ately on exposure, and in other cases not for some days. One attack 
does not procure an exemption from future ones. 

Pathological Anatomy. — The changes of structure proper to this 
disease are limited to the broncho-pulmonary mucous membrane. An 
intense hyperaemia takes place in the nasal, pharyngeal, laryngeal, 
tracheal, and bronchial mucous membrane. The hypersemia is usually 
confined to the larger tubes, but it may extend to the finer tubes, so 
that atelectasis may be associated with it. Pneumonia, both croupous 
and catarrhal, are occasional complications. In a portion of the cases 
the gastro-intestinal mucous membrane is also strongly hypersemic, 
and a quantity of watery or thick viscid mucus is produced, but this 
seems accidental. Doubtless, changes in the blood and in the ner- 
vous system, of a very subtile kind, must take place, for those occur- 
ring in the respiratory tract are not adequate to explain the nervous 
symptoms and the evidences of blood-poisoning. 

Symptoms. — The onset of the disease is sudden. There may be 
a decided chill, or chilliness alternating with flushing and heat, and 
fever at once comes on, soon rising to the maximum, but in other cases 
the febrile symptoms develop slowly, and do not attain their maximum 
until two, three, or even four days. The course of the fever is remit- 
tent, the exacerbations occurring at night. With the rise of tempera- 



INFLUENZA. 



873 



ture there is an increase in tlie pulse, the number of beats approximat- 
ing 100. At the same time a severe headache, located in the frontal 
sinuses and extending into the eyes, is experienced. Soon after the 
rise of temperature, in respect to which all observers are agreed, the 
symptoms of an acute catarrh come on : there occur heat, stuffing, 
dryness, quickly followed by increased secretion, and sometimes epis- 
taxis ; the conjunctivae are injected, and the eyes are watery ; present- 
ly the throat feels hot, dry, and irritated, and spots like measles are 
to be seen on the palate ; the mucous membrane of the mouth and 
tongue are also hyperaemic, but less so than the fauces. Soon the voice 
grows husky ; a troublesome cough, and, after a time, abundant thin, 
acrid mucus, and afterward purulent expectoration, are brought up, but 
at first the cough is hard, dry, and tormenting, especially in the even- 
ing and at night, and occasionally vomiting is excited by it. At first 
there is almost incessant sneeziug, but this subsides as the secretions 
increase. As the catarrh descends into the respiratory organs, the 
symptoms grow more serious. The expectoration may become bloody; 
more or less dyspnoea is experienced by many, and sharp stitches are 
felt in the sides ; sibilant and sonorous relies are audible over the tubes, 
and the signs, rational and physical, of pneumonia or pleuritis may be 
added to those of the disease proper. Instead of this gradual progres- 
sion of the symptoms from above downward, the nasal, pharyngeal, 
laryngeal, and tracheal mucous membrane may be affected simultane- 
ously. In ordinary cases the catarrh reaches its maximum on the sec- 
ond, third, or fourth day, and then declines, ceasing after some days 
longer. As the symptoms develop along the respiratory tract, in a por- 
tion of the cases the gastro-intestinal mucous membrane is affected. At 
first the oesophagus is attacked, then the membrane below. The appe- 
tite is gone, there is a good deal of nausea, and vomiting occurs spon- 
taneously, or is excited by the cough or by the presence of food. The 
epigastrium is painful and there are colicky pains ; sometimes diar- 
rhoea occurs — sometimes there is obstinate constipation. A remarkable 
phase of this disease consists in the disturbance of the nervous sys- 
tem, which is quite out of proportion to the gravity of the local dis- 
ease or to the amount of fever. From the beginning the patients 
appear anxious and depressed, and are weak, unequal to any exertion, 
and confused by any attempt at mental effort. There are general 
muscular pains and soreness, flying pains along the course of the prin- 
cipal nerve-trunks, but the chief source of suffering is the frontal head- 
ache. Besides the hebetude of mind observed to a less or greater 
extent in all cases, there is sometimes delirium ; in still other cases a 
remarkable state of somnolence has been noted. Vertigo is present in 
most of the cases ; and in some there is a decided hypersesthesia of the 
skin of the head and neck. Sweating is not usual at first, and if it 
occur soon is significant of an early subsidence of the fever, but it is 



874 



MIASMATIC DISEASES. 



one of the critical phenomena marking the termination of the disease. 
When there is much sweating, sudamina are present. The urine is 
usually lessened in amount and sometimes scanty or suppressed. The 
sweat is said to be highly acid, and the urine also acid and high-colored. 

Course, Duration, and Termination. — There are great variations in 
the intensity of epidemics and of individual cases. Some races suffer 
severely, others slightly. Children are less susceptible, and have the 
disease more mildly. The weak and cachectic and the aged run 
greater risks than the robust and young. Uncomplicated cases pursue 
their course in from four to eight days ; the fever reaches its maxi- 
mum on the third, fourth, or fifth day, and then terminates by crisis 
or by lysis. The critical phenomena consist in a profuse sweat, a free 
urinary discharge, an attack of diarrhoea, or an epistaxis. In the cases 
declining by lysis, several days are occupied in the return to the nor- 
mal state. Relapses are by no means uncommon. Cough and expec- 
toration due to bronchitis may persist for some time after the disease ; 
the nervous symptoms may linger and delay convalescence, or complica- 
tions may arise, or sequelae follow after the disease proper. Capillary 
bronchitis and catarrhal pneumonia may result by an extension of the 
morbid process from the bronchial tubes. A severe conjunctivitis, 
tonsillitis, or laryngitis, may develop from the usual implication of 
these parts. Besides these diseases, which are merely exaggerations of 
ordinary lesions, existing maladies may be much aggravated by an in- 
fluenza. Those so affected are especially phthisis, emphysema, dilated 
heart. Pregnant women attacked with influenza are apt to abort. 
Notwithstanding its apparently profound impression on the organism 
of man, the poison of influenza is scarcely lethal. The mortality of 
the last epidemics has not exceeded two per cent, where the disease 
appeared most noxious. Fatal cases, when they occur, seem to be due 
to the complications which arise in the course of them or to the sequelae. 

Treatment. — Repose in-doors, a generous diet, and the moderate use 
of stimulants, are the most important measures. At the outset a full 
dose of quinine and morphine (gr. xv — gr. ss.) exercises a favorable in- 
fluence ; and throughout the disease these are the most useful reme- 
dies to quiet the harassing cough and to maintain the strength. If 
there is much secretion, cocaine, locally, and. atropine, may be com- 
bined with the morphine and quinine. If the bronchial mucous mem- 
brane is severely attacked, small doses of tartar emetic, or ipecac and 
morphine, are useful Ext. ipecac fl. 3 ij, tinct. opii deodor. 3 iv, 
tinct. aconiti rad. 3 i. M. Sig. Six to ten drops every two hours). 
If the finer tubes are involved, the preparations of ammonia, the 
iodide, muriate, and carbonate of ammonia, should be freely admin- 
istered. If the stomach is very irritable, as is the case in many epi- 
demics, the most useful remedies are oxalate of cerium, hydrocyanic 
acid, minute doses of morphine subcutaneously, carbolic acid, with or 



HAY-FEVER. 



8T5 



■without bismuth, etc. For the violent head symptoms which some- 
times ensue, the most appropriate remedies are bromide of potassium, 
gelsemium, duboisine, morphine subcutaneously, etc. If there is much 
local distress, the vapor of hot water should be sedulously inhaled. 
When the first irritation is felt in the nares, a solution of hydrochlo- 
rate of quinine should be applied and allowed to pass through into the 
fauces, after the manner of Helmholtz. It is probable that pilocarpine 
will be found extremely useful in cases of influenza, administered at 
the outset with the view to abort the malady. Pellets of cocaine 
placed in the nares, and allowed to dissolve slowly and pass along the 
cavities posteriorly, have proved to be an effective application. 

HAY-FEVER— SUMMER CATARRH. 

Definition. — Hay-fever is an acute catarrh of the upper air-pas- 
sages chiefly, occurring at a fixed period annually, and disappearing 
after a variable duration. It has received a variety of designations 
besides those above given, as hay-asthma, rose-told, June cold, au- 
tumnal catarrh, etc. 

Causes. — Those who suffer from an annual visit of hay-fever refer 
their malady to a variety of causes, and it is probable that various 
kinds of emanations excite the disease. It is an interesting fact that 
three members of our profession, themselves sufferers from the disease, 
have made the most important contributions * to our knowledge of this 
affection. By Dr. Bostock the disease was supposed to be of a spe- 
cific nature, and he rejected, from the point of view of his own experi- 
ence, the supposed agency of emanations from new-mown hay or 
grasses. Wyman was unable to come to any conclusion in regard to 
the supposed agency of minute organisms, whether animal or vege- 
table, but he has carefully indicated the geographical position of the 
hay-fever zones in this country. Wyman's attention was directed to 
autumnal catarrh, as this is the form from which he suffered ; on the 
other hand, Bostock recognized the disease as it occurs in June. 
Probably the most important investigation ever undertaken is that 
of Blackley, who has shown that the pollen of rye produced the most 
violent symptoms of hay-asthma, notably sneezing, profuse catarrh, 
and oppressed breathing, and that the pollen of grasses, of wheat, oats, 
and barley was, next to rye, the most active in causing catarrhal 
symptoms. Further experiments showed that the pollen in the atmos- 
phere consisted in the large proportion of ninety-five per cent, of that 

* "Autumnal Catarrh (nay-Fever)," by Morrill Wyman, M. D., 18'72; " Experi- 
mental Researches on the Cause and Nature of Catarrhus jEstivus (Hay-Fever or Hay- 
Asthma)," by Charles H. Blackley, London, 1873, second edition, London, 1880. The 
disease was first described by Dr. Bostock, giving his own case, " Medico-Chirurgical 
Transactions," vol. x, part 1, p. 161 ; also ibid., vol. xiv, p. 437, " On Catarrhus iEstivus." 



876 



MIASMATIC DISEASES. 



from the grasses— the graminacece. That these observations and the 
conclusions based on them are correct, can hardly be denied. But it is 
probable that other influences are also necessary. Beard has lately pub- 
lished a monograph * based on a study of two hundred cases, from which 
it appears that there are several factors concerned in the production 
of this singular malady. He concludes that hay -fever is essentially a 
neurosis ; that the same form of disease occurs m the spring, summer, 
and fall ; that it is hereditary, and a product of modern civilization, 
and that, when the predisposition exists, various exciting causes may 
develop the disease. We believe that these propositions are correct. 
When the neurotic temperament is present, and a special tendency 
exists, various exciting causes, as heat, dust, but especially the pollen 
of grasses, of rye, corn, and rag-weed, may excite summer catarrh. 
Various cases have been published, showing that a mental impression 
may excite the disease. Phoebus mentions a case in which the symp- 
toms of hay-fever were excited in a susceptible patient by looking at 
a highly realistic picture of a hay -field. 

Symptoms.— There are two forms in which the disease manifests 
itself — the catarrhal and the asthmatic — but they are often united in 
the same individual. Hay-fever is distinctly periodical ; it occurs at 
certain seasons only, which differ in different cases ; and, in many 
persons, it comes on with unfailing promptitude on a certain day. 
Whether it occur in the spring, summer, or fall, its clinical features 
are the same. 

Catarrhal Form. — There may be warnings of the approach of the 
disease in a sense of lassitude and weariness, inaptitude for exertion, 
loss of appetite, a coated tongue, diarrhoea, or constipation, etc., but in 
a great majority of cases the onset is sudden. In the enjoyment of 
the usual health, the first symptoms are felt, although it is true those 
who have had the disease for years know full well the time of its ap- 
proach, and probably experience various subjective symptoms, which 
are purely mental in origin. The first symptom is an itching of the 
eyes, nose, behind the posterior nares, and the palate. This is fol- 
lowed by the flow of a transparent serous fluid, and then sneezing 
begins, which is most aptly described by Henry Ward Beecher, him- 
self a sufferer from the disease : " You never before even suspected 
what it really was to sneeze. If the door is open, you sneeze. If a 
pane of glass is gone, you sneeze. If you look into the sunshine, you 
sneeze. If you sneeze once, you sneeze twenty times. It is riot of 
sneezes. First a single one, like a leader in a flock of sheep, bolts 
over ; and then, in spite of all you can do, the whole flock, fifty by 
count, come dashing over in twos, in fives, in bunches of twenty." 
The eyes water, and the conjunctiva reddens ; the nasal mucous mem- 

* " Hay-Fever or Summer-Catarrh : its Nature and Treatment," New York, Harper 
& Brothers, 1876, pp. 266. 



HAY-FEVER. 



8TT 



brane swells and becomes bvperaemic ; and so great is the swelling in 
many instances that the two sides of the passageway approximate, 
and breathing is then carried on by the mouth. When the swelling 
occurs, the sneezing is less persistent, or ceases altogether ; the dis- 
charge which was clear and watery becomes yellowish and thicker, or 
it may be reddish from an admixture with blood. A very unpleasant 
sense of heat and burning is felt about the nose and eyes, and pain, 
which is rather lancinating, shoots through the orbits and frontal 
sinuses, and sometimes into the head. The throat is hot, dry, and 
somewhat swollen, and, in consequence of extension of the swelling to 
the orifices of the Eustachian tubes, the hearing becomes obtuse, and 
pain sometimes is felt in the ear. 

Asthmatic Form. — This begins at the same time, and i-uns its course 
with the catarrhal form, or, after an uncertain period, succeeds to the 
latter. In either case an extension of the morbid process takes place 
to the larynx and bronchial tubes, which become swollen and hyper- 
semic ; a hoarse laryngeal (croupy) or a wheezy bronchial cough 
occurs, and asthmatic difficulty of breathing is experienced in varying 
degrees of severity, from a mere sense of constriction to extreme dysp- 
noea. In the worst cases the same phenomena are exhibited as in 
the severe cases of asthma : the patient is unable to lie down, struggles 
for breath, is pale, and covered with a cold sweat. Remissions occur, 
but the difficulty of breathing does not entirely cease until the hay- 
fever is over, and in some subjects more or less bronchitis, with occa- 
sional dyspnoea, persists for two or three months afterward. Yery 
alarming symptoms may arise from an extension of the disease to the 
finer bronchi (capillary bronchitis), or congestion of the lungs may 
unexpectedly occur, or an attack of pneumonia supervene. Unless 
some of these secondary diseases happen, the constitutional symptoms 
are by no means severe. The pulse is a little accelerated, the temper- 
ature slightly, if at all, elevated, except during and for a short time 
subsequent to the asthmatic attacks. The strength is somewhat re- 
duced, the appetite is rather poor, and the discomfort sufficient to 
render a patient miserable. 

Course, Duration, and Termination— The disease behaves in a 
definite manner in all cases, and comes on and goes off with the 
strictest regularity. The duration of individual cases is from a few 
days to three months, the average being about six weeks. As locality 
is an important element in the causation, the behavior of cases is much 
affected by the surrounding conditions. As a rule, if the patient 
remain at the same place, the violence of the attacks rather increases 
year by year. Those at first assuming a merely catarrhal form, after 
a time become asthmatic, and in some instances the author has known 
the asthma to become a chronic condition, and to occur throughout 
the year. On the other hand, timely removal from the hay -fever zone 



878 



MIASMATIC DISEASES. 



may entirely prevent seizures. Although hay-fever never proves fatal, 
and usually leaves no sign, it may lead to the development of more 
serious ailments, as asthma, chronic bronchitis, impaired hearing, etc. 

Treatment. — For those who possess the means to travel, there is 
no remedy so effectual as removal from the hay-fever zone in time to 
prevent the attack. A sea-voyage, so arranged that the patient is on 
the ocean at the time of the attack, or residence in Europe, especially 
in Switzerland, during the same period, is always effectual. There 
are various parts of the United States where exemption from the 
seizures may also be secured for one or many years, but the immunity 
does not always continue indefinitely. The White Mountains, the 
Catskills, the highest points of the AUeghanies, the Adirondacks, and 
the Rocky Mountains, are to be recommended. Many seashore places 
can be resorted to with confidence of relief, so long as the breezes blow 
from the ocean : Fire Island and the Isles of Shoals are among the 
most desirable. Certain parts of Canada, Mackinaw, and Marquette, 
on the upper lakes, are suitable resorts for many cases. As no specific 
has been discovered, the remedies are very numerous. As is the case 
in the neuroses, a remedy acting favorably on one occasion will usually 
fail to relieve when employed again. Quinine has been more useful 
than any other agent, and may be depended on to give more or less 
relief if used efficiently. Before the access of the paroxysm it should 
be administered in the quantity of five grains three times a day for a 
week, and, when the first symptoms of irritation of the nares are felt, 
a solution of the muriate (the most soluble salt) should be applied to 
the nares. When the disease has begun, the best results are obtained 
from full doses of the iodide of potassium — fifteen grains every four 
to eight hours. If an abundant secretion is poured out, atropine will 
be found highly useful. The author has had excellent results from 
minute doses of morphine and atropine (morphine sulphate gr. -J, atro- 
pine sulphate gr. -g-J-o) when the paroxysm is well advanced. When 
asthmatic symptoms are experienced, the most useful remedies are 
iodides and grindelia. Local applications are, if rightly managed, 
more efficient than internal remedies. Carbolate of iodine may be ap- 
plied by the post-nasal syringe thoroughly to the posterior nares, and 
by the straight syringe through the anterior nares (]^ Acid, carbol. 
3 iij, tinct. iodi 3 v. M. Sig. Add from one to five minims to a 
gill of water). A simple expedient consists in vaporizing iodine and 
cautiously inhaling the vapor through the nares. This may be accom- 
plished by placing a few drops of the tincture in a warm vial. Solu- 
tions of chlorate of potash, of chloride of sodium, and of iodide of 
potassium, properly diluted, are also used with effect by the syringe 
and douche. Cocaine in solution, or in the form of pellet placed along- 
side the septum and allowed to dissolve slowly, has proved to be the 
most effective agent for affording relief. The dose will be ^—^ gr. 



WHOOPING-COUGH. 



8Y9 



WHOOPING-COUGH— PERTUSSIS. 

Definition. — Whooping-cough is a specific disease, occurring chiefly 
in childhood, and once only during life, and characterized by succes- 
sive forcible expirations, and at their termination by a loud, resounding, 
sonorous inspiration. 

Causes. — Rosenthal has shoYv^n that irritation of the internal branch 
of the superior laryngeal nerve produces relaxation of the diaphragm, 
spasm of the glottis, and a convulsive expiration— the series of acts 
which constitute a paroxysm of whooping-cough. Hence, we may 
conclude that the special exciting cause of this disease is a contagious 
principle which acts upon the respiratory organs, with special excita- 
tion of the filaments of the superior laryngeal nerves. The nature of 
this principle has hitherto escaped recognition. The morbific mate- 
rial may excite the disease at any age, but it is most common from the 
first to the seventh year, and it happens in females more frequently 
than in males. Pertussis occurs among all races and classes, and is 
more prevalent in winter and spring, although it is encountered at 
other seasons. As epidemics of whooping-cough sometimes precede, 
accompany, or follow epidemics of measles, a relationship has been 
supposed to exist between them ; but there is no real foundation for 
such an opinion. One attack removes the susceptibility to the disease, 
and it is uncommon for a second attack to occur in the same individual. 
The period of incubation is, probably, about ten days, but it varies 
considerably. 

Pathological Anatomy. — The only lesions are hypersemia of the 
mucous membrane of the nares, pharynx, larynx, bronchial tubes, etc., 
increased secretion after a preliminary dryness of the membrane, the 
secretion at first consisting of transparent mucus, afterward becoming 
more or less purulent, and, when this condition has been reached, the 
redness of the membrane is succeeded by paleness and ansemia. Vari- 
ous pulmonary and cerebral lesions occur also during the course of 
whooping-cough, but these are complications not necessary to the 
disease. 

Symptoms. — There are three well-defined stages of the ordinary or 
common form of the disease — the catarrhal^ the spasmodic, and the 
terminal — and there is a complicated form. The catarrhal stage can 
not be differentiated from an ordinary catarrh. There occur coryza, 
more or less cough, and slight fever with evening exacerbation, and 
morning remission or intermittence, general malaise and loss of ap- 
petite. After one or two weeks the cough changes its character ; it 
becomes more persistent, and assumes a somewhat spasmodic and 
paroxysmal character. As a rule gradually, but sometimes suddenly, 
the characteristic whoop is heard. Then the paroxysms have a dis- 
tinctive character : the cough consists of a succession of short, rapid. 



880 



MIASMATIC DISEASES. 



expiratory efforts ; the face gets red ; the eyes swell and protrude ; 
the body is more and more bent forward in the effort at coughing ; 
then, when the breath is entirely exhausted, a deep, loud, crowing in- 
spiration occurs. During each paroxysm there may be two, three, or 
more of such efforts, and at the expiration of them the patient brings 
up a quantity of tenacious, glairy mucus, which is dislodged with diffi- 
culty, and is often accompanied by vomiting. In the progress of the 
case, the expiratory effort is less, the inspiratory is not so long delayed, 
the secretion becomes less viscid and more purulent, and vomiting oc- 
curs less frequently. The peculiar whoop or sonorous inspiration is 
after a time wanting to some of the paroxysms, and ultimately ceases 
altogether. During the paroxysm, the expiratory effort coincides 
with a partial occlusion of the glottis, the venous blood accumulates, 
and more or less cyanosis of the face and head is produced ; haemor- 
rhage may occur from the nose, the ears, rarely from the bronchi, and 
under the conjunctiva. The frequent collision of the under surface 
of the tongue with the front teeth excites an ulceration of the fraenum 
and neighboring portion of the tongue. In some cases the sudden 
compression of the abdominal organs, produced by the coughing, gives 
rise to the formation of hernia, to prolapse of the bowel, and to invol- 
untary evacuations. The duration of the paroxysms varies from a few 
seconds to several minutes, and the number of them, daily, is very va- 
rious, ranging from ten to a hundred, the average being about twenty 
or thirty. During the period of maximum severity, the attacks are 
rather more numerous by night than by day, destroying sleep, which 
may ultimately induce a serious state. The frequent vomiting, also, 
causes such a loss of aliment that considerable weakness and emacia- 
tion result. On the other hand, when the paroxysms are widely sepa- 
rated, the health may be fairly well maintained. The action of the 
heart is very rapid during the paroxysm, but in the interval it may be 
normal, unless the system is reduced. The skin is more or less relaxed, 
and during a paroxysm may be covered with sweat. Attacks are in- 
duced by various causes. Imitation is a strong motive ; the presence 
of food in the stomach and the inhalation of dust or irritating fumes 
of any kind may excite attacks. When the paroxysm is about to ap- 
proach, the child takes refuge with its nurse, or seizes hold of some 
object of support, the face turns pale, and then comes the explosion. 

Course, Duration, and Termination.— In a well-defined case of the 
ordinary form the course is tolerably uniform. The catarrhal stage 
continues two or three weeks, the spasmodic three or four, and the 
terminal stage a week or two, although it may be prolonged by a 
cough of habit. The course of whooping-cough may, however, be 
much modified by the occurrence of comjylications. These occur chief- 
ly in the lungs and the brain. In every severe case of whooping- 
cough there is probably more or less pulmonary congestion, due to the 



WHOOPING-COUGH. 



881 



interference with the respiration occasioned by the paroxysms of 
coughing. When this occurs, the breathing is more or less oppressed 
in the intervals between the paroxysms ; the face is constantly some- 
what cyanosed ; the action of the heart is quick ; the pulse is weak, 
and the general condition is depressed. A frequent and very fatal 
complication of w^hooping-cough is capillary bronchitis, with the at- 
tendant accidents of atelectasis and broncho-pneumonia. Not unfre- 
quently these complications lead to caseous pneumonia, emphysema, 
dilated bronchi, and phthisis. If capillary bronchitis comes on, the 
greatly diminished aeration of the blood increases the passive cerebral 
congestion, and becomes, therefore, a cause of convulsions in children. 
The cerebral complications consist in convulsions and hydrocephalus, 
the result, chiefly, of the mechanical obstacles in the course of the cir- 
culation. The fluid is poured out in the ventricles, in the perivascular 
lymph-spaces, and in the subarachnoid spaces, and the brain is more or 
less compressed and anaemic. Sometimes a vessel yields under the in- 
creased pressure in coughing, and cerebral haemorrhage results. These 
cerebral states are accompanied by the usual signs and symptoms. The 
duration and termination of a complicated case will, of course, be de- 
termined by the character of the complication. The usual termination 
of uncomplicated cases is in recovery, but there are exceptions to this 
statement. In young and feeble subjects, the action of the heart may 
be suspended by the expiratory effort in coughing, or exhaustion may 
result from loss of sleep and uncontrollable vomiting. 

Treatment. — Arising from the action of a morbific principle, whose 
nature is unknown, obviously no cure will be discovered until the 
nature of the cause is ascertained. The treatment must therefore be 
merely symptomatic. During the catarrhal stage, those remedies are 
employed that have been most useful in ordinary bronchial catarrh 
{^ Syrup, scillse comp. 5 j> tinct. aconiti rad. TTi xvi, tinct. opii deo- 
dor. TH,. viij, syrup, tolu 3 vij, aq. lauro-cerasi 3 j. M. Sig. A teaspoon- 
ful every two, three, or four hours). Other formulae may be found un- 
der the head of " bronchial catarrh." The iodide and bromide of am- 
monium given together are highly beneficial during the catarrhal stage 
and as the spasmodic stage is about to develop. Tincture of aconite- 
root, tincture of belladonna, deodorized tincture of opium, and fluid 
extract of ipecacuanha, in suitable proportions according to age, is a 
most serviceable combination. Tincture of lobelia may be substituted 
for ipecac in the above formula, as advised by Ringer, who regards it 
as highly serviceable in whooping-cough. If the child is old enough, a 
gargle of bromide of potassium may also be used with advantage dur- 
ing this stage. As the spasmodic stage approaches, the antispasmodic 
remedies come into use. Probably the most eflicient of them all is 
opium, in the form of the alkaloid codeine, which can be employed with 
proper precautions, even in the case of infants. A slight hypnotic 
58 



882 



MIASMATIC DISEASES. 



effect should be maintained constantly, if we would obtain the best 
results from it. The bromides have an undoubtedly good effect in 
moderating the violence of the spasmodic attacks. Of these, the mono- 
bromide of camphor seems on the whole to be most beneficial. It can 
be given in an emulsion or pill-form, in from two to ten grains, every 
four hours. The very best results, and often an immediate arrest of 
the disease, can be procured by full doses of quinine. Not all cases 
are affected so favorably ; but in the author's experience no single rem- 
edy does so much good in this disease. Atropine often acts most 
favorably, but is uncertain. Cocaine locally and by the stomach is 
an effective remedy, and although acting similarly to atropine is a far 
more valuable remedy. The cough by habit, which remains after the 
subsidence of the paroxysms, is often admirably relieved by dilute 
hydrocyanic acid. This is also a useful remedy during the maximum 
of the disease. Excellent results have been obtained from the use of 
the mineral acids, especially nitric, in the treatment of the disease 
during its various stages. The acids should be well diluted, and given 
in some simple sirup, especially as large doses are necessary. Among 
the more recent remedies are quebracho and grindelia, which are re- 
spiratory sedatives, and are often highly serviceable. Some of the so- 
called mineral tonics — copper, zinc, and lead — have been administered 
with alleged success. Of these, probably, the best results have been 
obtained from acetate of lead, which is exhibited in from one fourth 
of a grain up to five grains, according to the age. If the tubes are 
much obstructed by mucus, or if capillary bronchitis supervene, emet- 
ics may become imperatively necessary. The yellow subsulphate of 
mercury, alum, apomorphine, and ipecac, are the emetics best suited 
to the purpose. Good results are obtained by the inhalation of car- 
bolic spray in many cases. An atomizer may be used directly to de- 
liver the spray in the fauces, or indirectly by filling the air of the 
apartment. A one per cent, solution is strong enough for this pur- 
pose. Like other neuroses, whooping-cough is much influenced by 
psychical impressions. Change of air and scene is therefore highly 
beneficial. To this mental impression must be referred the supposed 
agency of the ammoniacal odors of gas-works, and of such medicines 
as cochineal, which affect the mind by a brilliant color or disagree- 
able odor. 

PAROTIDITIS— MUMPS. 

Definition. — Mumps is a specific inflammation of the parotid gland, 
propagated by a peculiar miasm, self-limited, occurring usually as an 
epidemic, and characterized by a tendency to migrate into the mamma 
or testes. 

Causes. — ITothing is known of the materies morhi which give rise 
to this disease, except their effects. In from five to twenty days after 



MUMPS. 



883 



exposure of a healthy person to the atmosphere about an individual 
having the " mumps," the former is also attacked. It occurs most fre- 
quently in males, but also attacks females, and the usual age is from 
five to fifteen ; but, during the war of the rebellion, large numbers of 
raw recruits were affected, whose average age was not less than twenty. 
Like other diseases of the same class, it usually occurs but once in the 
same individual. 

Symptoins. — There is an initial or prodromic period, which may be 
so slight as to escape observation. It begins with chilliness, general 
malaise, sometimes vomiting, and a fever comes on immediately, with 
the usual signs and symptoms of that state. In from twelve to thirty- 
six hours an acute pain is felt behind the angle of the jaw, and pene- 
trates to the throat, frequently into the ear. The jaw becomes stiff, 
and a swelling appears immediately under the ear and extends for- 
ward and upward, forming an immense protuberance in front of the 
ear and behind and beneath the angle of the jaw. To the touch, 
doughy and elastic, it does not pit, and is very sensitive. It is usually 
confined to the parotid gland, but in severe cases, as seen in the army, 
the neighboring glands are implicated, and an enormous swelling, 
reaching as low as the sternum, results. In the ordinary cases the 
maximum enlargement is reached in from three to six days, remains 
stationary for one or two days, and then rapidly subsides, completing 
the revolution in from eight to twelve days. In some cases the swol- 
len part becomes intensely red, the color disappearing on pressure, to 
return immediately after the pressure is removed, and the epidermis 
desquamating as the STv^elling subsides. In consequence of the swell- 
ing, which often extends to and involves the neighboring tonsil, and 
the pain produced by all movements of the jaw, there is much diffi- 
culty in mastication and deglutition. When sapid substances, espe- 
cially acids, are taken into the mouth, an acute pain shoots through the 
cheek into the swollen gland and ear. Speech is also more or less 
painful and difficult, and the voice is muffled and indistinct. A viscid 
saliva continuously flows from the partly-open mouth. Often only 
one parotid is affected, and the other is attacked in a day or two, but 
it not unfrequently happens that several years elapse before the second 
gland is infected. A so-called metastasis not unfrequently takes place, 
of which the author has seen a number of examples. During the 
existence of the parotid swelling, the corresponding testicle becomes 
painful and swollen, and often a slight bruising of the organ invites 
the disease. Sometimes the swelling abandons the parotid, when the 
testis begins to enlarge. This seems like a true metastasis. The mam- 
ma, labia majora, and the uterus, are the organs in the female to which 
the disease is " translated " ; but such an accident must be excessively 
rare. In some instances an interval of several hours occurs between 
the disappearance from the parotid and the appearance elsewhere. 



884 



MIASMATIC DISEASES. 



with the effect to produce alarming symptoms of depression, anxiety, 
almost of collapse. 

Course, Duration, and Termination. — The course of the disease is 
much affected by the hygienic surroundings of the patient and by the 
constitutional state of those attacked. During the late war, the cases 
of mumps were accompanied by high fever, often delirium, and by great 
depression of the vital powers ; pneumonia was a not unfrequent com- 
plication, and those who recovered had a tedious convalescence, the 
blood being much impoverished and the body emaciated. Under or- 
dinary circumstances, mumps is a mild disease, which always termi- 
nates in recovery, its duration varying from four to ten or twelve 
days. The importance of mumps is to be regarded from another point 
of view. In some persons, the subjects of a dyscrasia, the morbid 
condition is awakened from its dormant state by an attack of mumps. 
The tubercular diathesis is the most common of these. Rarely has the 
gland suppurated, when attacked by mumps, but suppuration is the 
usual result when an inflammation of the parotid occurs in the course 
of typhoid fever. Atrophy is said to have taken place, but this must 
be an excessively uncommon event. The glands to which translation 
has occurred usually recover in a few days, without receiving any in- 
jury. The author has seen several cases in which the testes were 
injured — the damage consisting not in atrophy, but in an epididymitis, 
with occlusion of the spermatic duct. 

Diagnosis. — The prevalence of an epidemic, the occurrence of swell- 
ing in the parotid gland with fever, and the subsidence of the swelling 
and fever in a few days, are clinical features which readily separate 
mumps from other affections. In children having bad teeth there may 
be produced a swelling of the parotid and submaxillary glands, but 
here the pain and swelling about the tooth will explain the nature of 
the case. Inflammation and suppuration of the parotid will be differ- 
entiated by the formation of pus and by the usual symptoms of glan- 
dular inflammation. 

Treatment. — As this is a self-limited disease for which we have no 
remedy, it is wisest to attempt no perturbating treatment. Relief to 
the pain is best afforded by some warm applications, and by the inter- 
nal use of morjDhine and quinine. A mild laxative should be adminis- 
tered, and, if the skin is hot and dry, the body may be sponged off 
with cold water, and some tincture of aconite administered. Recent 
observations have apparently demonstrated that pilocarpus possesses 
a peculiar curative power. This may be given in the form of the fluid 
extract, or of the alkaloid pilocarpine, and is well worthy of further 
trials. The patient should be kept in-doors, and every effort made to 
avoid the least contusion of the testes. 



INTERMITTENT FEVER. 



885 



MALAEIAL DISEASES. 



INTERMITTENT AND REMITTENT FEVERS. 

Definition. — Malarial fevers are characterized by their prevalence 
in certain regions of the world known to produce the poison, malaria, 
by their periodicity, and by the regular succession of the cold, hot, 
and sweating stage. Various designations have been applied to these 
forms of fever, such as /ever and ague, chills, hilious fever, bilious re- 
mittent, etc. 

Causes. — The great etiological factor is malaria. The telluric and 
other conditions favorable to the development of malaria exist largely 
in this country, along the Atlantic seaboard as far north as Boston ; 
in all that great interior region drained by the Mississippi and its 
tributaries, the valley of the Sacramento on the Western coast, etc 
For an exhaustive account, the reader is referred to the recent work of 
Lombard, or to Hirsch.* The presence in the atmosphere of a mor- 
bific principle, which is developed when certain atmospheric and tel- 
luric influences exist, is now almost universally admitted. Although 
the existence of such a principle is admitted, the attempts to isolate 
and define it have proved abortive, unless the recent discovery of 
Klebs and Tommasi-Crudeli supply the missing form.f The " Bacil- 
lus Malarise," which they have discovered floating in the atmosphere 
of the Pontine marshes, produces paroxysms of intermittent fever in 
the animals subjected to its action by inoculation. If this discovery 
is confirmed, and these rod-like bodies are proved to be the cause of 
those phenomena which we call malarial fever, it will prove to be the 
first and most important step toward permanent eradication of the dis- 
ease. Malaria is also called " marsh-miasm," because of the abundance 
of this poison about marshes. But not all marshes produce malaria. 
The " Dismal Swamp," for example, is free from marsh-miasm, although 
apparently well adapted to produce it. Its exemption is supposed to 
be due to the growth of the cypress-tree. Marshes, or moist alluvium, 
subject to annual overflow, and exposed to the action of the sun, by 

* For an account of the great interior valley of this continent, see the monumental 
work of Dr. Daniel Drake (" A Systematic Treatise, Historical, Etiological, and Practical, 
of the Principal Diseases of the Interior Valley of North America," page '723), for the 
reasons which induce him to accept the doctrine of the cryptogamic origin of malarial 
diseases. 

f Klebs und Tommasi-Crudeli. "Studien iiber die Ursache des "Wechselfiebers und 
iiber die Natur der Malaria," '* Archiv fiir experimentelie Pathologic und Pharmacologic," 
Bd. xl, s. 311. 



886 



MALARIAL DISEASES. 



reason of evaporation or subsidence of the water, is peculiarly active 
in the production of the poison. Marshes that are partly brackish are 
worse than those entirely fresh. In this country malaria is produced 
more from the sandy alluvium of the river valleys subject to annual 
overflow and heated by the summer's sun. The alluvium and some 
very sandy soils of the malarial zone, not subject to overflow, also gen- 
erate malaria, which is freed by turning up the soil. Cultivation and 
drainage, however, ultimately destroy the malaria-breeding grounds, 
and marshes, drained and planted, finally cease to produce the miasm. 
The malaria zone extends northwardly as far as the isothermal line of 
59° to 59*8° Fahr., or to 63° north latitude.* It is the mean annual 
summer temperature, however, which determines the northern limits 
of malaria, and this pursues an irregular line which may be at some 
points above, at" others below, the sixty-third parallel. One important 
factor is elevation, malaria not breeding above five thousand feet above 
the sea, which seems to be the maximum limit. The apparent excep- 
tions to this afforded by the so-called " mountain fever " of Colorado 
will be alluded to hereafter. The period of the year during which 
malaria is most active is summer and fall — from June till November — 
for at this period only has the sun sufficient power. During the sea- 
son of its greatest intensity, the poison may be carried up ravines to a 
considerable elevation, or to distant points. A position to the leeward 
of an infected locality is, therefore, particularly dangerous. That ma- 
laria is soluble in water and is contained in the surface-water of in- 
fected districts seems now to be well established. The author found 
the surface-water of Kansas to produce malarial fevers and cholera. 
Some trees possess the property of absorbing and fixing in their own 
structures noxious principles contained in the soil. The common sun- 
flower, planted in moist lowlands, will render the air salubrious. The 
eucalyptus-tree has changed the nature of the malaria-breeding por- 
tions of Algiers, and is accomplishing the same sanitary result for the 
Campagna of Rome. The air is filtered of its disease-germs by pass- 
ing through a belt of woodland ; even shrubbery a few feet high serves 
the same purpose, and protects those living to the leeward. All ages 
are susceptible to malarial poisoning ; and all races are equally so, 
except the black. Males are somewhat more liable, probably because 
they are more exposed to the causes. Women suffer more from the 
masked forms, as hemicrania, supra-orbital neuralgia, etc. All causes 
depressing the vital forces favor the reception of the poison and the 
outbreak of the disease. Especially is exposure to cold and dampness 
combined apt to cause an attack. Previous attacks increase the sus- 
ceptibility. If those living in the midst of a malarious influence go 

* The forty-seventh parallel is given by Drake {supra) as the northern limit in this 
country, and the summer temperature of 60° Fahr. 



INTERMITTENT PEVER. 



887 



from it into a region entirely free from all suspicion of the infection, 
an outbreak of the fever is apt to occur. When malarial infection is 
established in the system, all diseases occurring will have more or less 
of the periodical character. The form of the malarial disease occur- 
ring will depend on the condition of the system, and on the intensity 
of the poison itself. 

Pathological Anatomy. — The changes caused by malarial poisoning 
are essentially the same, except degree, in all the forms in which the 
disease manifests itself, and two organs (the liver and spleen) are 
chiefly concerned. In acute cases, the spleen is much enlarged, splenic 
pulp greatly increased in relative quantity, and sometimes there are 
infarctions. Gangrene, abscess, and rupture of the spleen are acci- 
dents which have been observed in some cases of pernicious fever. In 
some chronic cases the spleen undergoes enormous enlargement ; its 
texture is tough and smooth on section, and it has a grayish slate color 
This change consists in a hyperplasia of the trabeculse with hyper- 
trophy of the capsule, but in some cases the increased size of the organ 
is due to amyloid degeneration. When the organ attains to very large 
dimensions, it is known as "ague-cake." Usually, in chronic malarial 
poisoning, the spleen is somewhat enlarged, but not so much increased 
as to be called ague-cake, the change consisting in a diminution of the 
splenic pulp and an hypertrophy of the trabeculse and capsule. The 
color of the spleen is grayish or slate, due to pigment deposits, which 
are found in greatest abundance in the walls of the blood-vessels, 
where it is deposited by disintegration of the red globules. Important 
changes take place in the liver. During an intermittent the liver be- 
comes hypergemic and swollen, and, if jaundice is present, very much 
enlarged, stained with pigment, and the portal capillaries distended 
with blood, and the gall-bladder filled with thick, tarry, dark-brown 
bile. In chronic cases the liver has a grayish tint, due to pigment de- 
posits along the vessels ; it is firm in texture, and the divided parts 
preserve sharp outlines ; the hepatic cells are pale and filled with fat- 
granules. The intestinal canal also presents characteristic changes. 
During an acute attack there are extensive and considerable hyper- 
semia of the mucous membrane and more or less thickening and eleva- 
tion of the solitary and agminated glands. In the chronic cases the 
intestinal mucous membrane has a general slate-colored hue, due to pig- 
mentation of the capillaries. The glands, solitary and agminated, are 
thickened and enlarged from accumulation of their contents and hyper- 
aemia, and thickly disseminated through the groups of Peyer are the 
black orifices of the follicles of Lieberkuhn. The kidneys are also 
affected by characteristic changes : hypersemia during the acute attack, 
and subsequent alterations, as thickening of the basement membrane, 
the tubules filled with cast-off epithelium, the interstitial connective 
tissue proliferating, and more or less amyloid change in the Malpighian 



888 



MALARIAL DISEASES. 



tufts and small arteries.* The brain and spinal cord do not escape. 
In ordinary cases during an acute attack, there is more or less hyper- 
hernia of the brain ; in pernicious remittent, capillary pigment embo- 
lisms and minute extravasations occur ; but more usually the condition 
is that of hyperaemia and cedema of the membranes and of the cerebral 
matter. In the lungs there may be infarctions, croupous pneumonia, 
etc. The heart is flabby, its muscular fiber easily torn, the right cavi- 
-ties distended with soft, black coagula, very loose. The changes in 
the blood have not been studied with accuracy. Bence Jones's dis- 
covery of a fluorescent substance in the blood and tissues has not 
thrown any light on the question, since this substance or rather reaction 
is very widely distributed and is without importance. It is true. Pepper 
and Rhoads found this substance diminished by malarial fever, but 
nothing has resulted from these observations. The white corpuscles 
are much increased in numbers relatively, but the most important 
change in the composition of the blood is the formation of pigment 
from the hsemoglobulin, the haematin is set free, and is found in all the 
principal organs associated with the vessel- walls, and rarely collected 
in masses, and forming capillary embolisms. 

Symptoms. — Prodromal Stage. — A certain period elapses after ex- 
posure before there is any disturbance in the functions. This period 
of incubation varies from a few hours to many weeks, the variations 
being due to the intensity of the poison and the susceptibility of the 
individual. The average which is most usual is fourteen days. In a 
large proportion of cases there are symptoms indicating that the infec- 
tion is working. These are called prodromes. The patient has a feel- 
ing of lassitude and weariness ; he suffers with backache and general 
muscular soreness ; he has an irresistible inclination to yawn and 
stretch, especially in the early morning, and on cold, damp days ; his 
head aches, tongue is coated, stomach is squeamish ; toward evening 
his skin becomes warm and dry, his sleep is disturbed by dreams, and 
in the early morning a profuse sweat occurs. In other cases the pro- 
dromes consist merely in a coated tongue, yellow sclerotic, and a gen- 
eral yellowish hue of the skin, languor, loss of appetite, and constipa- 
tion ; the urine is loaded with bile-pigment, and deposits an abundance 
of urates. Gradually thus may the patient drift into a paroxysm of 
fever, without there being any distinct initial symptom — the form 
assumed developing by a process of selection, as it were, out of the 
material offered. Or the disease may begin abruptly in the midst of 
apparently full health, or during the puerperal state, or in the course 
of chronic malarial poisoning. 

Intermittent Fever. — Ague and Fever. — There are three distinct 

* The author gives the results of numerous observations and studies made during his 
service in the regular army, from 185Y to 1864. (See his contributions to United States 
"Sanitary Commission Memoirs," medical volume.) 



INTERMITTENT FEVER. 



889 



events in every paroxysm of intermittent fever : the chill, the fever, 
and the sweat. When the chill comes on, there is a feeling of wretched- 
ness, of weariness, and illness. There occur headache, backache, and 
soreness in the muscles of the extremities. Creeping chills are felt 
along the back, there are gaping and praecordial oppression, the whole 
surface grows cold, and, feeling extremely weary and depressed, the 
patient gladly betakes himself to bed ; but the coldness intensifies, no 
matter how much covering is piled on ; the fingers become blue, the 
iips blue, the nose pinched, the countenance shrunken, and the chilli- 
ness is now aggravated into shuddering. One fit after another of 
shuddering comes on ; the teeth rattle together ; the bed shakes. 
Meanwhile the pains in the head and back and limbs continue ; there 
is extreme thirst, and often nausea and vomiting ; respiration is quick 
and sighing, the voice is weak and tremulous ; the pulse is small, rapid, 
and the tension high ; the urine is pale, watery, and increased in quan- 
tity. Notwithstanding the overpowering sense of coldness, it is found 
to be objective, for the temperature begins to rise with the onset of 
the chill, the thermometer indicating fever whether in the axilla, mouth, 
or rectum. The duration of the chill varies from a mere instantaneous 
chilliness to several hours of shaking, the usual length of the ague 
being a quarter to a half hour. The chill does not terminate abrupt- 
ly. The shaking subsides slowly, as a feeling of warmth gradually 
diffuses outwardly, or flashes occasionally through the limbs. After a 
time the body feels hot, the extremities grow warm, the pulse becomes 
fuller and stronger, the blueness of the skin is replaced by a red blush, 
the face is full instead of retracted, flushed instead of pallid. The 
pains in the back and limbs disappear, but the headache rather in — 
creases, and throbbing is felt in the temples, and with each pulsation 
of the carotid. The pulse grows full, rapid, and strong; respiration 
is more frequent and easy. The head becomes hot, feels full ; there 
are noises in the ears ; vertigo and nausea are experienced on the at- 
tempt to get up ; the ideas are confused, and the mind is dull, and 
there may be excitement and delirium. The usual symptoms attend 
this feverish state — there are thirst, a dry mouth, constipation, high- 
colored, scanty, and acid urine. The duration of this stage varies from 
an hour or two to ten or twelve, and it is succeeded by the third or 
sweating stage. While the fever is raging, a gentle moisture appears 
on the forehead and face, and more abundantly in the axilla, groin, 
between the thighs, and then on the skin. Presently the moisture 
increases to drops, and finally pours off, wetting the shirt and the 
sheets. As the sweating progresses, the fever declines, the pulse be- 
comes softer and its tension is lowered ; the headache and other pains 
and the general muscular soreness cease ; the mouth gets moist and 
the thirst lessens ; the respiration becomes easy and regular, and the 
patient, although exhausted, experiences a feeling of comfort and well- 



890 



MALARIAL DISEASES. 



being, and often falls asleep. The sweat is acid in reaction, is ricli in 
salts, and contains a large quantity of organic matter with fat acids, 
to which its animal odor is chiefly due. The urine also is acid, has a 
high color owing to a quantity of pigment, and contains much uric 
acid and urates, which are deposited abundantly on cooling. The 
amount of urea discharged corresponds closely with the range of tem- 
perature, and, as soon as the fit of ague begins, the production of urea 
increases (Ringer). A sudden decline in the amount of urea takes 
place during the sweating stage, and in the apyretic interval it is 
below the normal.* The excretion of chloride of sodium also is 
always increased greatly during the cold and hot stage of an ague 
paroxysm. These facts indicate that the increased temperature of the 
febrile movement represents the consumption of tissue. When the 
paroxysm is entirely ended by the completion of the sweating stage, 
in about twelve hours, on the average, from the beginning of the seiz- 
ure, the patient presents evidences of the revolution through which he 
has passed. There is experienced a sense of exhaustion, and the func- 
tions generally are depressed ; the tongue coated, the a;gpetite poor, 
the epigastrium and hypochondriac regions more or less uneasy and 
sensitive to pressure, and the skin is slightly or considerably jaundiced, 
Not every ague attack is so severe, and great variations are observed 
as regards the several stages. Thus the chill may be a mere creeping 
or crawling sense of coolness along the spine, while the fever and 
sweat may be extremely severe. Again, the chill may be pronounced 
and the fever and sweat trivial ; or there may be profuse sweating at 
regular intervals, without any but the most trivial and transient dis- 
turbances in other respects. 

Course, Duration, and Termination.— After a certain interval, which 
is different in the several types of fever, the paroxysm recurs, and 
there are again presented the phenomena of chill, fever, and sweat. In- 
termittent fever follows a definite law of periodicity. Sometimes the 
paroxysms occur daily, coming on at a special time with nearly uni- 
form particularity. This variety or type is known as quotidian inter- 
mittent. Again, the paroxysms occur on alternate days — on the third 
day, including the days of attack — and are hence known as tertian in- 
termittent. In the temperate malarious regions the tertian form is 
the most frequent. There is still a third variety, in which the parox- 
ysms occur on the fourth day, including the days of illness, and hence 
is known as quartan intermittent. This last variety is uncommon. 
Sometimes two distinct paroxysms occur on the same day, and hence 
we have double quotidian^ double tertian^ etc. The author has en- 
countered two cases of double quotidian in the puerperal state. Other 

* Dr. Joseph Jones, "Trans. Amer. Med. Association," 1859, vol. xii, p. 507; Sydney 
Ringer, " Medico-Chirurg. Trans.," second series, 1859, vol. xxiv, p. 361; Dr. Parkes, 
"On the Composition of the Urine in Health and in Disease," London, 1860, p. 235. 



IXTERMITTENT FEVER. 



891 



eccentricities have been observed. Thus, a quotidian may have on 
alternate days corresponding paroxysms as to time and character, and 
may consist of two tertians. Such a variation is sometimes called a 
double tertian. The triple tertian is a variety in which there are two 
distinct paroxysms on one day and one paroxysm on the next ; the 
duplicated tertian has two paroxysms on alternate days ; and, finally, 
the double quartan has a paroxysm on one day, a milder one the next 
day, and a day without fever. The duration of a paroxysm of fever 
varies with the type : the quotidian lasts from eight to twelve hours, 
the tertian from six to eight, and the quartan from four to six. The 
paroxysms do not always occur at the same hour ; if uninterfered with 
they anticipate, the second occurring a little earlier than the first, and 
the third earlier than the second. On the other hand, as the force of 
the attack is declining, the paroxysms are postponed. The quotidian 
usually begin in the early morning, the tertian toward or at noon ; 
if not interfered with by treatment, an intermittent will ultimately 
terminate spontaneously, but the period at which this result will be 
reached depends on the climate, constitution, season, degree, in which 
the system has been poisoned by malaria, etc. Very mild quotidians 
may terminate in a month, tertians in two months or longer, and 
quartans many months. When malarial poisoning has thoroughly oc- 
curred, the disposition to attacks continues for a long period — often 
for years. Exposure to cold, errors of diet, fatigue, mental anxiety— 
a variety of causes, of sufficient force to disturb the functions — may 
excite a new attack. Yery often a change of type ensues : the quo- 
tidian may become a tertian, or the gravity of the case is increased — a 
remittent succeeding to an intermittent fever. It is rare for an inter- 
mittent fever to terminate in death directly, but indirectly, through 
the various alterations occurring in malarial poisoning, a large mortal- 
ity results. The course of intermittent is much diversified by the va- 
riations from the typical form known as masked intermittent. When 
an attack has been interrupted by the exhibition of the usual remedies, 
there may occur at the regular periods subsequently a mere temporary 
rise of temperature, a profuse sweat, a copious urinary discharge, an 
attack of diarrhoea, etc. With or without any previous manifestation 
of fever, those affected with malaria may suffer with various substitu- 
tion diseases, as intermittent hsematuria, pulmonary haemorrhage, bron- 
chitis, coryza, iritis, jaundice, diarrhoea or dysentery, vomiting, urtica- 
ria, roseola, and numerous other maladies. These substitution diseases 
agree in coming on at a fixed hour or nearly so, in disappearing after 
a time without any apparent reason, in coming on again at the ap- 
pointed time or anticipating a little, and in yielding promptly to the 
anti-periodic while obstinately resisting other means of treatment 
Probably the most common of these substitution diseases is neuralgia 
and the most usual position of this, the ophthalmic division of the 



892 



MALARIAL DISEASES. 



fifth ; but it may occur in the other divisions of this nerve — in the oc- 
cipital nerve, in the sciatic, and elsewhere. In what position soever 
the neuralgia appears, the attacks are periodical, and usually quotidian. 
When it occurs in the ophthalmic division, there are intense pain 
in the region of the eye and forehead and throbbing temples, the con- 
junctiva is injected, and the eyelids are swollen ; general malaise, nau- 
sea and vomiting, some chilliness, elevation of temperature, and sweat- 
ing are the systemic symptoms, which associate these cases with the 
ordinary intermittents. When sciatica occurs it may assume the in- 
termittent or remittent form, is on the right side in the majority, and 
is sometimes accompanied by clonic spasms. Not frequently, attacks 
occur in the cardiac nerves, producing the phenomena of angina pec- 
toris, viz., pra3cordial oppression and pain, a sense of impending 
death, great difficulty of breathing, a slow, hard pulse, cold skin, 
blue lips and fingers, ending with free eructations of gas, the dis- 
charge of a quantity of pale, watery urine, etc. Various nervous dis- 
eases, as delirium, puerperal mania, hallucinations, coma vigil, etc., 
have occurred, as those above mentioned, in substitution of malarial 
attacks. Besides the intermissions, the regularity in the periods of 
recurrence, and the promptness with which they yield to quinine, 
these substitution maladies may be accompanied by some of the other 
objective phenomena of malarial fever. 

Pernicious Intermittent, — In those parts of the United States 
where the malaria is most concentrated and the malarial fevers most 
severe, the ordinary intermittent may assume a most formidable char- 
acter, termed periiicious in scientific works, and popularly known as 
congestive. That an attack of intermittent will assume a pernicious 
character is not announced in advance. Sometimes the condition of 
exhaustion induced by a severe attack of cholera morbus may invite a 
paroxysm which assumes the pernicious character, or the state of the 
patient may be rendered unfavorable by some other malady, or there 
may be present some symptoms of cerebral disturbance, but in general 
there is nothing to indicate the approach of the severe type. Usually, 
the case has the ordinary aspect of an intermittent for the first, second, 
and third paroxysm. There may be a gradual increase in the severity 
of each attack, or the usual type may be followed by a pernicious one. 
It is not often that the first pernicious attack proves fatal, but a repe- 
tition of them becomes more and more dangerous, and after the first 
any succeeding attack may be fatal. The pernicious attacks assume 
several forms — the algid, choleriform, diaphoretic, the pneumonic, the 
nephritic, and the cerebro-spinal.* In the algid form the depression of 
the heart, which is its distinctive feature, comes on either in the fever 
or sweating stage. While intense internal heat is experienced by the 



* Jaccoud, op. cit., p. 605. 



INTERMITTENT FEYER. 



893 



patient, the surface becomes cold, livid, and cyanosed, the pulse small 
and exceedingly rapid, the action of the heart feeble ; the skin is cov- 
ered with a cold, sticky sweat, but the mind is undisturbed. If death 
occurs, the condition of coldness and depression increases, but if recov- 
ery, after a longer or shorter duration of the algid state, the action of 
the heart grows a little stronger, and gradually warmth is restored to 
the sui-face. In the choleraic variety of pernicious fever there is pro- 
duced an algid state resembling that of cholera, by an uncontrollable 
vomiting and purging, and the resemblance is carried to the stage of 
reaction ; for if the patient emerge from the condition of collapse he 
experiences the fever of reaction — the typhoid state — which occurs 
under similar circumstances in cholera. In the sioeatmg or diaphoretic 
variety of pernicious intermittent no notable change in the demeanor 
of the case takes place until the stage of sweating arrives, when, not 
only does an enormous transpiration occur through the skin, but the 
temperature falls below the normal, the circulation becomes exceed- 
ingly depressed, the surface cold and cyanosed ; the urinary secretion 
is greatly diminished or totally suppressed, and in many cases there are 
passed large, whitish stools, without bile. Under such circumstances 
there may be more or less jaundice, and by many authors those cases 
characterized by a marked biliary derangement are erected into a dis- 
tinct class, 2iS pernicious ^c^er^c-( Jaccoud). When the vaso-motor dis- 
turbance, which underlies the forms of pernicious intermittent, already 
described, is precipitated on some internal organ, there will ensue, in 
addition to the condition of coldness, cyanosis, and feeble circulation, 
the symptoms of some particular internal malady — pneumonia or pleu- 
risy, for example. A malarial pneumonia pursuing the ordinary course, 
the symptoms remitting in accordance with the type of the malarial 
fever, will, if the pernicious symptoms set in, assume, in a short time, 
a condition of extreme danger, owing to the disturbance in the pulmo- 
nary circulation. When the vaso-motor derangement affects the kid- 
neys during the course of pernicious intermittent, there is produced the 
nephritic form of pernicious fever, and the signs are hsematuria, al- 
buminuria, or suppression of urine. The most common form of perni- 
cious intermittent is that affecting the nervous centers. There are 
usually some j^reliminary symptoms, as headache, vertigo, and a sopo- 
rose state, which are present during the first paroxysms, or in the in- 
terval preceding the pernicious attack. During the fever stage the 
patient falls into a profound coma, and this is all the more dangerous, 
because it may resemble natural sleep. In the first attack, the patient 
usually rallies during the sweating stage, in twelve to twenty-four 
hours, or the coma may simply deepen, the heart become more and 
more depressed until death. The succeeding attacks are usually fatal. 
This comatose form may assume an appearance of apparent death, the 
patient being in a cataleptic condition, or it may be preceded by faint- 



894 



MALARIAL DISEASES. 



ing-fits, a state of genuine coma then coming on. In still other cases 
this cerebral form of pernicious fever may assume the appearance of 
maniacal delirium, or it may affect the brain and cord simultaneously, 
causing tonic and clonic spasms, etc. In this country the most fre 
quent varieties of pernicious intermittent are the algid, the choleraic, 
the pneumonic, and the comatose. 

Sequelae of Intermittent Fever. — When attacks of intermittent fever 
have been interrupted by appropriate treatment, relapses are apt to 
occur. In fact, by the treatment only the objective phenomena of 
fever may have been removed, and consequently but a certain time will 
be required to develop new paroxysms. In cases thus temporarily 
suspended and apparently well, it will be found on close inspection 
that there are still occurring in regular sequence certain disturbances. 
The thermometer may show some slight elevation of temperature; 
there may be a distinct sweat, or a profuse urinary discharge may occur, 
and, after a period determined by the type, the paroxysms will recur. 
These relapses are said to appear on the seventh, fourteenth, and twen- 
ty-first days, but it is more correct to state that the periods of recur- 
rence are multiples of the first or former attacks. If, for example, the 
case is tertian, the first relapse would occur on the sixth day ; if quo- 
tidian, relapses would take place on the third, sixth, ninth, and twelfth 
days ; and thus on. Not only the regular cases, but the various masked 
and pernicious forms, manifest the same tendency and pursue the same 
laws as regards the relapses. The tendency to the occurrence of re- 
lapses is much affected by age — is much greater under twenty, and 
declines rapidly after twenty. The time at which they occur varies 
greatly, from one week to six months, but the probability of a relapse 
is very slight after six weeks have passed. The type of the disease 
frequently changes in undergoing a relapse, the tendency being to 
more frequent attacks, the tertians becoming quotidian. The ten- 
dency to relapses is due to the persistence of the conditions which de- 
termined the first seizure. The result of the long-continued action of 
malaria is most disastrous. The blood loses its red globules, while the 
white diminish in size and increase in number ; the ankles become 
(Edematous ; the liver and spleen enlarge ; the skin is yellow, earthy, or 
jaundiced ; the body emaciates ; the appetite is poor, the digestion 
feeble, the stools clay-colored, and the urine may contain albumen, and 
is deeply colored with bile-pigment ; fluid accumulates in the peri- 
toneal cavity, etc. Palpitation of the heart and a venous hum over the 
course of the great vessels occur because of the watery state of the 
blood, and for the same reason epistaxis takes place and the menses 
become profuse. The changes which affect the composition of the 
blood are due to various causes — to the interference by stomach and 
intestinal troubles with the primary assimilation, to the morbid state 
of the blood-making organs, especially to the destruction in the spleen 



REMITTENT FEVER. 



895 



of the red-blood globules, and to the conversion of haematin into pig- 
ment, which we have shown to take place at various points. An impor- 
tant fact is the accumulation of this pigment, and its almost universal 
distribution throughout the body. The mischief done by pigment em- 
bolisms is doubtless very great. Besides those changes belonging to 
chronic malarial intoxication and the sequelae above mentioned, there 
are various maladies of high importance, which may have their origin 
in the malarial cachexia. Among these are nephritis, amyloid degen- 
eration of the liver, kidneys, spleen, and intestinal glands ; sclerosis of 
the liver, anaemia, dropsy, tuberculosis, neuralgia, epilepsy, hemiplegia, 
mania with suicidal tendency, etc. 

Diagnosis. — A case of intermittent, complete at all points, could 
hardly be confounded with any other malady. It may be mistaken 
for pyaemia, in which there are chills, fever, and sweats, with an 
apyretic interval. It differs, however, from pyaemia in its origin, and 
in the clinical course ; intermittent is due to a supposed miasm — pyae- 
mia to wounds, suppuration of veins, etc. ; intermittent is regular in 
its course — pyaemia is very irregular, no defined intervals occurring ; 
intermittent is a benign affection, promptly cured by quinia — pyaemia 
is a fatal disease, over which quinia has no influence. Masked inter- 
mittents are differentiated from the local maladies whose form they 
assume, by the fact that malaria is abundant, that these diseases are 
distinctly periodical, and that they yield to the remedies for malarial 
diseases. The diagnosis of the various pernicious forms is very dif- 
ficult. It ought to be remembered that the pernicious attack has 
occurred at a time when the regular paroxysm is due, and that prob- 
ably a strong malarial influence prevails. The comatose variety is 
often preceded by symptoms indicative of the disturbance in the intra- 
cranial circulation, such as headache, vertigo, sopor, etc. 

Remittent Fever. — The remittent fever of this country is known as 
bilious fever and bilious remittent fever. The designation bilious has 
been applied because of the prominence of the symptoms referable to 
the hepatic function. Every summer and fall this disease prevails 
largely through the South and West. The author saw in Kansas, in 
185T, at the military post of Fort Leavenworth, a great many examples 
of the severe form of remittent fever prevalent in that locality. The 
cases of remittent are divisible into three groups — mild, severe, and 
grave. These divisions, generally recognized by systematic writers, 
are based on clinical experience. In the mildest form the fever con- 
tinues for four or five days, when distinct intermissions occur ; the 
remissions are well defined from the beginning, and increase day by 
day into the complete intermission. Usually an attack of remittent 
fever is preceded or accompanied by a coated tongue, yellow and 
thick ; a heavy, offensive breath ; nausea and vomiting — the matters 
ejected consisting, for the most part, of acid mucus and bile ; violent 



896 



MALARIAL DISEASES. 



headache, especially of the frontal region, ringing in the ears, throb- 
bing temples, and a chill of moderate severity, which marks the real 
onset of the disease. The remission is every day (quotidian type), or 
on alternate days (tertian type), and is marked by a distinct sweat, 
which coincides with the decline of temperature. More or less chilli- 
ness, sometimes a well-defined chill, begins the new paroxysm. Rest- 
lessness and wakefulness at night, bleeding at the nose, a slight bron- 
chitis, and an eruption of herpes, are also symptoms of this form. In 
the severe form the fever is less broken by remissions, and assumes a 
type approaching the continued. About the third day there are be- 
ginning symptoms of cerebral derangement, as stupor and delirium ; 
the tongue is dry and cracked ; the spleen and liver are enlarged and 
swollen ; a well-marked icterus stains the skin, and in some cases 
pernicious symptoms are developed out of a complicating dysentery 
or pneumonia. Such a case may extend over two weeks, and gradu- 
ally abate into an intermittent, or terminate fatally, with pernicious 
phenomena, in collapse. In the grave form the case may begin as in 
the severe variety ; in the first week the exacerbations and remissions 
will be irregular, perhaps, with a tendency, constantly increasing, 
toward a continued type, delirium and stupor coming on, and deepen- 
ing into coma. Instead of a gradual progress toward a typhoid state, 
the case may begin with serious symptoms, and in a few hours deliri- 
um, jaundice, hjemorrhages, albuminuria, or suppression of urine may 
appear. In other cases, choleraic symptoms or dysentery may come 
on, purulent effusions into the serous sacs may occur, a pneumonia may 
develop, abscess may form in the liver, and gangrene of the skin may 
result. A form of remittent fever of great severity, and having close 
analogies with yellow fever, is that known as the Jimmorrliagic bilious 
fever. It may commence as an ordinary intermittent, but the grave 
symptoms rapidly develop. The chills are protracted and violent, 
intense headache and backache are then experienced, a burning pain 
passes from the pharynx to the stomach, very depressing nausea now 
comes on with vomiting of bilious matter, obstinate constipation is 
succeeded by a bilious diarrhoea, the urine is copious and dark in color, 
the skin assumes an icteric hue, and very considerable swelling of the 
spleen and liver occurs. Meanwhile the fever becomes remittent and 
the remissions less and less marked, the pulse rapidly declines in vol- 
ume and strength, the skin is covered with a cold sweat, the features 
shrink, haemorrhages occur from the mucous surfaces, the urine lessens 
greatly in quantity or is entirely suppressed, and the fatal result is 
reached in an increasing coma. Notwithstanding the formidable 
character of this variety of remittent fever, a fatal result is not inevi- 
table, if the subject be vigorous, and the treatment properly carried 
out before the onset of coma, which may appear on the fourth, fifth, or 
sixth day. So strong is the resemblance of these cases to yellow fever 



REMITTENT FEVER. 



897 



that they are doubtless often confounded during the epidemic preva- 
lence of the latter. No means of distinction between them is so satis- 
factory as the action of quinine, which will arrest the one but not 
affect the other. 

Treatment. — The questions of public and private hygiene involved 
in the prevention of malaria are beyond the scope of this work. The 
direction which the investigation of physicians should take is in- 
dicated in the etiological chapter. The measures of prophylaxis, as 
affecting individuals, must, however, receive some attention. Those 
living in malarious regions, susceptible to the action of the poison, 
must avoid all excesses of every kind, exposure to fatigue, to heat, and 
to rapid alternations of temperature. Exposure to the night air and 
to the early morning air is also to be avoided. Before leaving the 
house in the morning a substantial breakfast should be taken, and a 
prophylactic dose of quinine, if the season of malarial production has 
arrived — summer and fall. The experience now accumulated as to the 
prophylactic power of quinine puts this question beyond controversy. 
The English naval experience on the coast of Africa, the military ex- 
periences in India and Africa, and our own experience during the civil 
war, have demonstrated that the daily administration of a sufficient 
dose will procure immunity against malarial infection. The quantity 
required for this purpose is differently stated, but should be determined 
by the supposed intensity of the malarial poison, and may be put at 
from five to ten grains daily. It is best administered in the early 
morning, and in some black coffee, or dissolved by the aid of sulphuric 
acid in water, in pill form, or simply in water. The practice pursued 
in our army during the war, of giving quinine in whisky, is wrong in 
principle, and the results were not good, therapeutically or morally. 
The effects of quinine as a prophylactic are much more certain than 
when used in a corresponding way to prevent relapses. In fact, it is 
much easier to prevent than to cure the disease. If there is no time 
to prevent the paroxysm, we possess means to abort it at the chill 
stage. The expedients resorted to for this purpose are very numer- 
ous, and include nitrite-of-amyl inhalations ; chloroform by inhalation 
and by the stomach ; the hypodermatic injection of morphine and of 
pilocarpine. From a half-drachm to a drachm (fluid) of chloroform, 
given in some sweetened water, by the stomach, or administered by 
inhalation, will usually arrest the chill, and greatly lessen the severity 
and duration of the succeeding stages. Amyl nitrite is also quite 
efficient in bringing on reaction and abbreviating the chill stage, but it 
exercises little or no influence on the other stages. Recent observa- 
tions seem to prove that pilocarpine, of all the remedies hitherto pro- 
posed for this purpose, exercises the most remarkable influence.* If 

* Dr. Griswold, August 16, 1879, " New York Medical Record." 
59 



898 



MALARIAL DISEASES. 



administered as tlie chill is coming on, it stops it, and substitutes a 
sweating stage, thus preventing the full evolution of the paroxysm. 
The most remarkable point is that the disease seems arrested, and 
relapses prevented, in a considerable proportion of the cases. If these 
observations are confirmed, we shall have in pilocarpine the most use- 
ful remedy in the treatment of intermittents. From one twelfth to 
one sixth grain of the nitrate or muriate of pilocarpine, given hypo- 
dermatically, is the appropriate dose for an adult, and this should 
be given as the chill is about to occur. A corresponding dose (one 
sixth to one fourth grain) can be given by the stomach half an hour 
before the chill-time. If the chill has anything of the pernicious char- 
acter about it, the most efficient remedy is the hypodermatic injec- 
tion of morphine and atropine, or of morphine alone. In any of the 
modes in which the pernicious attacks come on, the remedies are two — 
morphine and quinine — and the mode of administration subcutaneous. 
The usual means of applying artificial heat are of course to be used, 
but no time should be expended on anything until morphine and qui- 
nine shall have been injected subcutaneously. From one twelfth to 
one fourth of a grain of morphine can be given to an adult. Maximum 
doses of quinine are required. Much difficulty has hitherto been ex- 
perienced in preparing a suitable solution of quinine. As the muriate 
of quinine and the bromide are soluble to a much larger extent than 
the sulphate, they may be used for solution in water only ; but as the 
quantity required is so great, a solution of the sulphate, dissolved by 
the aid of sulphuric acid, is generally preferred.* The dose of quinine 
injected in a pernicious case should not be less than twenty grains, 
and this may be repeated two or three times until reaction is estab- 
lished. In the absence of the method or means of hypodermatic in- 
jection, quinine and morphine may be administered by the rectum, if 
insensibility or irritability of the stomach prevents the introduction of 
remedies into that viscus. If the approach of a pernicious intermittent 
is indicated by the presence of head-symptoms — drowsiness, headache, 
vertigo, etc. — the administration of full doses of quinine should not be 
delayed. 

In the treatment of ordinary intermittents, our attention is directed 
to the prevention of future attacks. Although no preparatory treat- 
ment is actually required, better results are obtained if the gastro- 
intestinal derangement is removed. If the tongue is heavily furred, 

* Ff, Quininse disulph., gr. 50 ; acid, sulphuric, dil., ni 100 ; aquae font., | j ; acid, 
carbol. liq., fi[6. Solve. 

For various formulse, see " Manual of Hypodermic Medication," by the author of this 
work, third edition, p. 213. 

Note. — The carbamidated muriate of quinine — a combination of muriate of quinine 
and urea — has been found to be the most effective as it is the most soluble of all the 
preparations, and is preferable to all others. 



KEMITTENT FEVER. 



899 



the stomacli irritable, and the bowels constipated, the absorption of 
quinine is much hindered and its powers lessened. A grain of calo- 
mel, followed in four or six hours by a Sedlitz-powder, or the latter 
without the calomel, will assist in the absorption of the quinine. The 
old plan of an emetic, followed by " ten of ten " — ten of calomel, ten 
of jalap — is no longer pursued. Opinions still differ as to the period 
of administration, and the dose of quinine, in the treatment of inter- 
mittent fever ; but these differences exist among those only who have 
but limited experience in the management of severe intermittents. 
The question is, shall we use small doses, frequently repeated in the 
interval, or a single full dose at the proper period before the access 
of the paroxysm? The latter is better, for these reasons : the whole 
effect of the quinine is obtained at the right time, a less quantity suf- 
fices, and the curative effect is greater. As the elimination of quinine 
takes place with considerable rapidity, appearing in the urine in three 
hours after it is swallowed, it is obvious that, if the administration 
has been distributed over twelve hours, the effects of the first doses 
are expended before the last are given. The amount necessary to 
arrest the paroxysms should, therefore, be given at a dose, or within 
a short period, and at a time preceding the chill sufficient to obtain 
the maximum effect, which is about three hours. For an ordinary 
intermittent from fifteen to twenty grains of quinine are necessary to 
stop the paroxysms. To prevent relapses, quinine must be given at 
certain periods : on the second or third day, and on the fourth and 
sixth days after the date of the first administration, according to the 
type. Having in view the tendency to relapse at subsequent periods, 
quinine should be again given on the twelfth to the fourteenth, and 
on the nineteenth to the twenty-first days. As, in cases of malarial 
cachexia, we have to deal with certain morbid conditions of the liver, 
spleen, intestines, blood, etc., attention must be given to them if we 
would effect a cure. To improve the condition of the blood, the 
chalybeates, notably the sulphate of iron, must be employed ; and 
these remedies are the more efficacious if combined with arsenic and 
other tonics. During the intervals between the administration of 
quinine, the remedies best adapted to the existing state of malarial 
cachexia are, besides iron, arsenic and eucalyptus. Various substitutes 
for the expensive quinine are now largely administered. Probably the 
best of them are the combined alkaloids of cinchona in an impure form, 
as used by the authorities of India, Quinidine may be prescribed in 
the same quantity as quinine, and seems about as effective. Cincho- 
nine is also quite effective in twice the quantity as quinine. The 
author has found the salicylate of cinchonidine quite a good anti- 
periodic, and next, probably, to the salts of quinine in power. Salicylic 
acid has some antiperiodic property, but greatly inferior to quinine ; it 
has been combined with quinine to form salicylate, but its precise 



900 



MALARIAL DISEASES. 



value has not been shown. Eucalyptus is a most useful antiperi- 
odic, but it is adapted rather to the treatment of malarial cachexia, 
and to prevent relapses. Iodine possesses a high degree of utility in 
the treatment of malarial intermittents, and may be used in substitu- 
tion for quinine, or to remove some of the secondary lesions. Lugol's 
solution is a convenient form in which to administer it. The combi- 
nation of iodine and carbolic acid is highly efficient (1^ Acid, carbol. 
3 j, tinct. iodi comp. 3 iij. M. Sig. Four drops every four hours 
in sufficient water). This combination may be depended on exclu- 
sively in some cases. For the removal of the various morbid altera- 
tions caused by malaria, the combination of iodide of ammonium and 
arsenic is most effective (to a solution of iodide of ammonium, giving 
five grains to the dose, add three drops of Fowler's solution). The 
practitioner will find this most useful in cases of chronic malarial poi- 
soning with frequent intermittents. For the treatment of enlarged 
spleen there is, besides the exhibition of quinine, no remedy more 
efficacious than the ointment of the red iodide of mercury, which is 
rubbed in daily over the splenic region in the sunshine, until soreness 
of the skin compels a suspension. For the gastro-intestinal catarrh, 
the duodenal catarrh, and the catarrhal jaundice, which occur so fre- 
quently in malarious regions, with or without any febrile movement, 
the most serviceable remedies are two, the phosphate or benzoate of 
soda, three times a day, and a morning and evening dose of ten grains 
of quinine. 

In the treatment of remittent fever the same general plan is to be 
pursued as in the management of intermittents. It is not necessary 
to await the remission, but the antiperiodic may be given at once, 
yet it is certainly true that the remedy in corresponding dose is 
much more efficient if given during the sweating. The author's first 
experience in the administration of large doses of quinine was gained 
under that able physician and medical officer, the late surgeon John 
M. Cuyler, M. D., of the Army Medical Staff, then stationed (1857) 
at Fort Leavenworth, Kansas. The author, a recent graduate in 
medicine, and just then admitted to the army, was very fortunate 
in being able to witness the practice of so experienced and able a 
physician. The large hospital of the post contained a number of 
the severe remittent fevers of that locality. They were broken up 
into intermittents and sent out of the hospital in a week, usually 
by the routine prescription of thirty grains of quinine the first morn- 
ing, twenty the second, fifteen the third, and ten the fourth — single 
doses, and all taken at once. As remittent fever is due to a more 
intense and concentrated poison, no delay in the efficient use of qui- 
nine is proper ; otherwise, it may lapse into the typhoid state, and be 
confounded with typhoid fever. The intermittent remainder requires 
the same management as an ordinary intermittent. Should there be, 



SCROFULA. 



901 



as is usual, great irritability of the stomach, quinine solution can be 
given by the rectum, and the usual remedies applied for the relief of 
the nausea and vomiting. If the rectum is also irritable and rejects 
the remedy, it must then be given hypodermatically. Whenever it is 
practicable to do so, the antiperiodic should be administered during 
the remission in the sweating stage. The almost numberless masked 
intermittents and remittents require the same management as an ordi- 
nary case of intermittent, except that they are more difficult to arrest 
and require maximum doses of quinine. 



DISOEDEES OF NTJTEITION. 



SCROFULA. 

Definition. — By scrofula is meant a constitutional dyscrasia, heredi- 
tary or acquired, characterized by changes inflammatory and hyperplas- 
tic, occurring for the most part in the lymphatic system, the skin, 
mucous membranes, connective tissue, osseous structures, and viscera. 
Scrofula is also known as struma^ the strumous diathesis, tuberculosis, 
the tuberculous diathesis, etc. 

Causes. — Heredity is the most influential factor in its pathogenesis, 
but it is the predisposition and not the disease itself which is inherited. 
Those cases are said to be innate in which, owing to conditions pres- 
ent in the parents, not themselves strumous, a scrofulous constitution 
is transmitted to their offspring. Such conditions are old age, blood- 
relations, cachexia of syphilis, etc., which existing in the parents, the 
offspring may possess the strumous constitution. Acquired scrofula is 
the product of various evil hygienic influences, as crowding, bad air, 
poor food, insufficient clothing, overwork, especially in youth, and in 
dark, damp, and crowded apartments. Kecent observations, especially 
those of Cohnheim, which indicate the essentially infective nature of 
tubercle — a product of scrofula — show the great danger of inducing 
tuberculosis in children by the consumption of milk from tuberculous 
cows. It is probable that many cases of acquired scrofula, especially 
in cities, are derived from this source. If a scrofulous predisposition 
exist in a latent state, it may be roused into activity by various 
causes. Certain diseases, as measles, whooping-cough, typhoid fever, 
etc., will have this effect. Scrofula manifests itself usually about the 
time of the first dentition, and increases from the third to the sev- 
enth year. It is rare for the manifestations to appear only after pu- 



902 



DISORDERS OF NUTRITION. 



berty. Glandular affections do not often occur before the second year. 
Scrofula prevails under all conditions of soil, climate, and elevation, but 
it occurs most frequently in those countries where crowding, bad air, 
and the other hygienic evils of dense populations are most abundant. 

Pathological Anatomy. — The anatomical changes occur in the lym- 
phatics, the skin, the mucous membranes, the bones and the viscera. 
As regards the lymphatics, the cervical, bronchial, mesenteric, inguinal, 
and others are affected by two processes — one, and the simplest, con- 
sisting of hyperplasia of the gland-elements ; the other, and more com- 
plex, being the formation and subsequent caseation of tubercle. From 
the hyperphasia may proceed an inflammatory process, involving not 
only the gland but the adjacent connective tissue and skin ; suppura- 
tion takes place, abscesses form, and fistulous tracks and sinuses are 
made by the discharge of pus. The first step in the caseation of the 
gland is an enlargement by hyperplasia, then miliary tubercles form, 
or, without them, cheesy masses develop in distinct layers from the 
hyperplastic materials, and ultimately the whole gland becomes case- 
ous. It is a disputed question whether there is a necessary devel- 
opment of the miliary tubercle precedent to cheesy degeneration, or 
whether the process of caseation develops out of the new hyperplastic 
materials. It is probable, as stated above, that both processes share in 
the production of the result. The cutaneous manifestations of scrof- 
ula consist in eczematous and impetiginous eruptions, situated on the 
face, scalp, or behind the ears ; and at the nose prominent pustules of 
impetigo with thick yellow crusts and suppurating beneath, the adja- 
cent nasal mucous membrane ulcerating, are the characteristic appear- 
ances. The mucous manifestations of scrofula are usually situated at 
or near the junction of the membrane with the external integument, 
and the cutaneous lesions are associated with the mucous. Thus, im- 
petigo of the lip is coincident with a scrofulous coryza ; otitis externa 
with retro-auricular eczema ; catarrhal conjunctivitis with eczema.of 
the neighboring cheek. Strumous coryza after some years becomes 
an ozoena, and affects by contiguity the post-nasal fossa. The mucous 
membrane of the larynx and bronchi, of the genito-urinary tract, and 
of the intestinal canal, may also be attacked. The broncho-pulmonary 
membrane is a favorite seat of strumous changes, and here they mani- 
if est a strong tendency- to ulcerative action. The connective tissue is 
affected by abscesses ; the joints become the seat of chronic synovial 
disease, of erosions, caries, etc. ; the periosteum inflames, the bones 
also, and caries and necrosis are ultimate results of the changes, or the 
primary disease may arise in the spongy portion of bone, especially in 
the vertebra, and the epiphyses of the long bones. In the viscera the 
most important of the lesions due to scrofula are those of the lungs — 
cheesy pneumonia, phthisis, etc., and those of the cerebellum, pro- 
ducing large, cheesy nodules. Amyloid degeneration of the liver, 



SCROFULA. 



903 



spleen, and kidney ; caseous infiltration of the supra-renal capsules 
and tuberculosis of the testes are also products of the strumous di- 
athesis. 

Symptoms. — There are two distinct types of the scrofulous consti- 
tution, the light and the dark, the irritative and the torpid. In the 
former the skin is white and transparent, the veins showing through 
with great distinctness, and blushing taking place with extreme facility ; 
the hair is soft, long, and fine in texture, and usually of light shade ; 
the eyes are large, blue, and brilliant, the pupils dilated, the sclerotic 
pearly ; the muscles are soft and flabby, the weight in proportion to 
size small ; the mental development is precocious, and puberty antici- 
pates the usual period.* The torpid form is characterized by a thick, 
coarse, and rather dark skin, a considerable preponderance of adipose 
tissue, the muscles being weak and relaxed ; the body is gross, the 
appearance puffy, the habit torpid and heavy ; the head is relatively 
large, the nose short and stubby, the upper lip thick and prominent ; 
the neck is thick and deformed by enlarged thyroid or other enlarged 
glands ; the abdomen is swollen and rather protuberant ; the legs 
small and relatively short. The intellectual powers correspond to the 
physical — they are slow, inactive, and wanting in strength. Although 
typical examples of these two forms are met with, many cases consist 
of a mingling of these types. They present the usual pathological 
conditions from infancy up. They are subject to attacks of coryza, to 
scrofulous ophthalmia, to otorrhoea and discharges from behind the 
ears, to vesicular and pustular eruptions, etc. Slight wounds of the 
skin are followed by protracted suppuration, by enlargement of the 
connected chain of lymphatics, and they heal with difficulty. During 
the first dentition obstinate impetiginous eruptions appear on the face 
and scalp (milk-crust), and, if the eruptive diseases attack these stru- 
mous subjects, severe nasal catarrh, otorrhoea, and unhealthy ulcera- 
tions linger long afterward. After the second dentition, the lymphatic 
glands begin to enlarge, and the scrofulides, or scrofulous skin affec- 
tions, make their appearance — as erythema, eczema, impetigo, ecthyma, 
and also lupus. Then follow affections of the mucous membranes, 
which are usually catarrhal, the discharge being yellow, thick, and 
drying easily, but it is highly irritating, causing about the nose, for 
example, obstinate eczema. The nose and the ear are special seats of 
scrofulous suppuration and discharge. The eye is affected by scrofu- 
lous ophthalmia, which is remarkable for its persistence and severity, 
and for the little damage done to the organ, if the affection be appropri- 
ately treated. The mucous membrane of the bronchi is a favorite seat 
of scrofulous inflammation, leading to caseous phthisis and tuberculo- 
sis. The lymphatic glands, as has been described, are affected in two 

* " General Pathology," Wagner, translated by Drs. Van Duyn and Seguin, New 
York, 18V6, p. 458. 



904 



DISORDERS OF NUTRITION. 



modes — by a simple hyperplasia, and by cheesy degeneration and tuber- 
culosis. When the affected glands become very large, forming great 
bundles, the surrounding connective tissue undergoing inflammation, 
the change consists in a cheesy degeneration and tuberculosis. Ab- 
scesses may form by suppuration of the connective tissue ; but these 
are superficial. When suppuration occurs in the substance of the 
gland, the skin overlying it is attached, becomes a characteristic 
bluish-red color, and ultimately breaks, the gland is exposed, and an 
ulcer is formed, having undermined, irregular, and livid margins. The 
ulcer thus formed may spread for some distance under the skin, and 
sinuses extend in various directions, and often burrowing quite widely. 
Healing of such scrofulous ulcers does not take place until the remains 
of the cheesy gland are finally extruded, and a large, unsightly, often 
thick and indurated cicatrix is left. Sometimes the glands enlarge 
enormously, but do not inflame and suppurate. Such bunches are 
often seen on both sides of the neck, filling in the whole space from 
the jaw to the sternum, and extending into the mediastinum. When 
large numbers of glands enlarge in this way, phthisis is more apt to 
follow than in the other form characterized by suppuration, according 
to the author's observation. The most severe of the scrofulous affec- 
tions are those of the bones and joints, notably fungous arthritis (Bill- 
roth). This disease appears most frequently in the knee, but attacks 
the other joints also, is very chronic in course, and terminates either 
fatally or in an anchylosed joint. Scrofula also attacks internal parts 
by affections of the lymphatics, as tabes mesenterica, or more frequently 
as cheesy pneumonia. The nutrition of the body does not necessarily 
fail. Large ulcers on the surface are not incompatible with very good 
health and considerable embonpoint ; but protracted suppuration of 
bone, disease of the mesentery, etc., make serious inroads on the vital 
powers, but the mischief induced by the amyloid degeneration, caused 
by protracted suppuration, is much greater. 

Course, Duration, and Termination. — The course of scrofula is essen- 
tially chronic. When one group of troubles disappears, another group 
comes on the stage. Its course is much influenced by the particular 
direction taken by the morbid process, whether it attacks the external 
lymphatics or those of the mesentery, the nasal mucous membrane or 
the bronchial, etc. In many instances the morbid influence expires 
about the period of puberty ; in others at this period phthisis develops. 
During the course of scrofula, general miliary tuberculosis may come 
on, or the protracted suppuration may cause amyloid degeneration of 
important internal organs, or a tuberculosis of the cerebellum may 
arise. So many elements enter into the solution of the problem that 
the duration can not be very definitely expressed, and the termination 
is affected by so many possible complications that no exact limits can 
be set for it. 



SCROFULA. 



905 



Treatment. — When acquired, the treatment of scrofula is a slow, 
difficult, and unsatisfactory procedure. Better results are obtained by- 
prevention when the existence of a scrofulous diathesis is suspected. 
Preventive measures, which must begin at birth, consist in saving the 
child from all those evil hygienic influences which are the chief excit- 
ing causes. A scrofulous mother should not nurse her child, which 
should be put to the breast of a healthy and vigorous wet-nurse. "When 
feeding begins, the diet should be properly proportioned, and should not 
be composed of more than the necessary amount of starchy food. Abun- 
dance of plain, substantial, and easily digested aliment should be sup- 
plied to the growing child ; its clothing should be arranged to protect 
the body, allow the limbs free motion, and afford the necessary warmth; 
confinement in-doors, especially to dark and damp habitations, should 
be prevented, and, if practicable, a healthy country life should be fol- 
lowed up to puberty, and the educational training should be conducted 
with reference to these essentials of the bodily training. If scrofula 
has already appeared under any of its modes of manifestation, the hy- 
gienic rules just referred to are even more necessary, but unfortunate- 
ly are attended with less success. As faulty nutrition is an important 
factor, our remedial measures should be early directed to improve the 
assimilative functions. The mineral acids and the bitters are very use- 
ful here. One of the most serviceable remedies for promoting construc- 
tive metamorphosis is the lactophosphate of lime, which is best admin- 
istered in the form of sirup. For this may be substituted the " phos- 
phates in the form of the compound sirup ; but the former is more 
efficient. Cod-liver oil is of great utility in scrofula, but it is better to 
reenforce the oil with the lactophosphate of lime. If suppuration is 
going on, the sulphides, according to Ringer, may be depended on to 
secure the rapid closure and healing of the surface ; but the author 
regrets to say that he has not succeeded so well with these remedies. 
If anaemia is a marked feature, the chalybeates are useful. The author 
finds the sirup of the iodides of iron and manganese a very efficient 
preparation. Iodine has had, since its first discovery, considerable 
repute as a remedy for scrofula, but this, originally derived from ob- 
servation of its effects on simple goitre, has not been confirmed by 
further experience of its use in the enlarged glands of scrofula. While 
this is true, it is also a fact that the iodides of iron are more efficient 
than the other chalybeates. Other remedies advocated for scrofula 
are the chlorides of calcium and barium, and they deserve a suitable 
trial in obstinate or protracted cases. A number of topical applica- 
tions have been proposed. The most efficient in our experience is the 
ointment of the red iodide of mercury. This can not be used when 
inflammation has begun in the skin. When scrofulous abscesses form, 
the pus should be drawn off with an aspirator, and the cavity then 
injected with tincture of iodine. When there are open ulcers, an ex- 



906 



DISORDERS OF NUTRITION. 



cellent application is iodoform mixed with tannin, the powder being 
blown by the insufflator into all the crevices. 

ACUTE MILIARY TUBERCULOSIS. 

Definition. — Acute miliary tuhercidosis is a febrile affection due to 
the deposit, generally, through the body, of the gray tubercle-granule. 
It should not be confounded with phthisis florida^ which is an acute 
caseous pneumonia. 

Causes. — The gray granulation, or miliary tubercle, consists of a 
fine reticulation of fibers, with a mass of epithelioid cells and granules, 
and the bacillus tuberculosis — the specific element. In acute miliary 
tuberculosis these minute bodies are widely distributed throughout 
the system. In the lungs they arise from the irritation of old lesions, 
from cheesy lymphatics, etc., and they are developed in various organs 
by the irritation of caseous deposits, of suppuration, of the products 
of serous and mucous inflammations, etc. Acute miliary tuberculosis 
is one mode of dying from consumption. That the gray granulation 
is deposited throughout the body under the influence of certain kinds 
of irritation, it is necessary that a peculiar vulnerability of the consti- 
tution exist — in other words, that it be of the scrofulous type. These 
deposits of miliary tubercle may occur at any age, but most usually 
from puberty to middle life. 

Pathological Anatomy. — In the brain, miliary granulations develop 
from the endothelium of the lymph-spaces, and are therefore found 
chiefly in connection with the pia mater. They occur also in the other 
membranes, and in the choroid. In the lungs they are contained in 
greater numbers than elsewhere, and are usually associated with and 
dependent on other changes in these organs. Nevertheless, both lungs 
may be infiltrated throughout with the gray granule, when free from 
any source of irritation. In that case the infection is found to proceed 
from some other source — from the bronchial glands, genito-urinary 
tract, or elsewhere. In addition to the tubercular deposition, the mu- 
cous membrane of the bronchi is generally hypersemic, and the con- 
gestion increases from the main bronchi downward. There is also 
increased secretion, the mucus having a somewhat adhesive and viscid 
character. Miliary granules are quite abundantly distributed in the 
pleura and peritoneum, as in the pia mater. The liver, spleen, and kid- 
neys, and the mucous membrane of the intestinal canal, are also more or 
less infiltrated. About the site of each granulation there is a patch of 
hypersemia, due to the presence of an irritating material. As so many 
organs are simultaneously invaded, it follows that their functions must 
be disordered. As the new formation develops from the vessels, some 
serious changes might be expected in the composition of the blood. 
Although not adequately studied, enough is known to show that the 



ACUTE MILIARY TUBERCULOSIS. 



90T 



blood is mucli altered. In the lungs, hypostasis takes place, and in 
various dependent situations the blood transudes. The blood itself is 
dark, and not readily coagulable. The heart is soft and flabby and its 
tissue easily torn. The spleen is also enlarged, the pulp much in- 
creased, and of a dark-brown color. 

Symptoms. — Acute miliary tuberculosis may arise in the course of 
phthisis, when, therefore, are exhibited the phenomena of a neiv, sud- 
den, and general infection in addition to the previously existing mal- 
ady. It may begin in those who have apparently good health, because 
the source of infection is dormant. It is with the latter class that 
we have to deal here ; the former have been sufficiently considered in 
the chapters on phthisis. As the symptoms of pulmonary, or cerebral, 
or of intestinal disturbance may predominate in different cases, divi- 
sions may be made accordingly ; but, without refining so far, it will 
suffice to describe the disease as a whole, referring to these peculiari- 
ties in passing. The disease sets in, after several days of general 
malaise, with a chill followed by fever, or there is more or less chilli- 
ness for the first day. The fever soon rises to a considerable eleva- 
tion ; there are headache, tiyinitus aurium, wakefulness, or sleep dis- 
turbed by dreams, epistaxis sometimes ; the countenance is dull, the 
eyes heavy, and the prostration is great from the beginning. The 
appetite is gone, the bowels are confined, but are moved copiously by 
mild laxatives, and the urine is scanty and high-colored. Soon after 
the onset of the disease, a short, dry cough, which is very harassing, 
comes on, but the most important symptom connected with the re- 
spiratory organs is a greatly increased rapidity of breathing, the res- 




FiG. 54.— Temperature Curves of Acute Miliary Tuberculosis. 



pirations numbering forty, fifty, even sixty per minute. The pulse 
is correspondingly increased, rising during the maximum to 140, 160, 
or higher, and falling not below 120. The tension of the pulse is low 



908 



DISORDERS OF NUTRITION. 



(dicrotic) and the action of the heart is feeble. The fever is usually 
of the remittent type of continued fever, or it has more of the remit- 
tent quality of malarial fever, or of hectic. The periods of remissions 
are characterized by sweats. The circulation in the extremities is 
feeble ; the finger-nails are blue, the lips and nose have also a cya- 
notic hue, and the countenance soon becomes dusky. On auscultation, 
some moist, crackling rales are audible over the chest, but there is no 
special change in the sonority. The difficulty of breathing, noted at 
the outset, increases and really amounts to dyspncsa. The tongue 
becomes dry ; sordes accumulate about the teeth ; food is rejected ; 
the abdomen swells with tympanites ; diarrhoea supervenes, the stools 
being thin and having a light-yellow color ; the spleen can be made 
out considerably enlarged, and occasionally rose-spots, not unlike those 
of typhoid, appear on the abdominal wall. After the first few days 
of headache, vertigo, and disturbed sleep, delirium occurs, but at this 
period the mental disturbance is only at the time of awaking from 
sleep ; by the end of the first week it has become nearly constant. 
In some cases, so preponderant is the deposit of gray granulations in 
the meninges of the brain that the symptoms are those of acute men- 
ingitis. In a majority of the cases, however, there is delirium of the 
low-muttering character. As the case progresses, a condition of som- 
nolence comes on ; the delirium is less and less active, and the stupor 
soon passes into coma. When this condition of the cerebral functions 
is reached, the dyspnoea, before so marked a feature, ceases to affect 
the respiratory center. When there is little or no deposit of miliary 
granules in the cerebral meninges, the functions of the brain are dis- 
ordered because of the high temperature which obtains in this disease. 
The cerebral symptoms, then, are those of depression — there is a good 
deal of hebetude of mind, followed by stupor. Should the deposits in 
the lungs be much in excess of those in the meninges, the cough, the 
dyspnoea, the moist rales, etc., will be more prominent than the head 
symptoms. When the intestinal mucous membrane is largely infil- 
trated with tubercle, the tympanites and the diarrhoea are decided. 
In every case w^hen fully developed, there are stupor and some low 
delirium, rapid breathing, cough, and dyspnoea, until coma comes on ; 
high temperature, rapid pulse, and weak heart ; swollen abdomen and 
diarrhoea, and an enlarged spleen. The cases, as a rule, present a 
striking analogy to typhoid, not only in the symptoms as above de- 
tailed, but in the physiognomy of the patient, the decubitus, the utter 
prostration, and in the course of the disease. 

Course, Duration, and Termination. — The course of an acute mili- 
ary tuberculosis is that of an acute febrile affection. The severity is 
determined by the extent of the tubercular deposits. The high tem- 
perature which prevails at the maxima is a measure of the diffusion of 
the tubercle-granules, but the fever in turn contributes to the gravity 



RICKETS. 



909 



of the case, by inducing the same parenchymatous changes which 
occur in typhoid. The cases assume somewhat different features, as 
above pointed out, whether the cerebral, the pulmonary, or the intes- 
tinal lesions predominate. The most usual type is that of a severe 
fever, having bronchial and intestinal complications, and more or less 
mental disturbance due to high temperature, and hence frequently 
confounded with typhoid fever. The duration varies somewhat in 
the different cases, being about four weeks in the largest number, but 
it may last six weeks or even three months. It is hardly doubtful 
that death is the invariable termination. The mode of dying is by 
exhaustion and failure of the heart, by pulmonary obstruction and 
dyspnoea, and by a gradually deepening coma. 

Treatment. — The consideration of the treatment of acute miliary 
tuberculosis is a rather barren subject, since it does not appear that 
any remedy has the least influence over the disease. The treatment 
must hence be symptomatic, and confined to remedies for relieving 
the abnormal temperature, or for maintaining the power of the heart. 

RICKETS. 

Definition. — Rickets is a constitutional disease of childhood, char- 
acterized by a disorder of nutrition in which the growth of the bones 
is irregular, calcification is imperfect, and deformities ensue. It is also 
called osteomalacia, rachitismiis, rachitis, etc. 

Causes. — Rickets occurs everywhere, but there are certain parts of 
the globe where the cases are more numerous than elsewhere, because 
the conditions are more suitable. Over-populated communities, the 
people poor, and living in dark and damp habitations, insufiiciently 
fed and clothed, are the social circumstances under which rickets de- 
velops. It is common in the great cities of England, and of Europe 
generally, and rather infrequent in this country. Parry,* it is true, 
reports that " at least twenty-eight per cent, of all the sick children, 
between one month and five years old, that have come under his ob- 
servation during the last three years, have been rachitic." This state- 
ment is based on observations in the children's department at the 
Philadelphia Hospital. Meigs and Pepper, also, of Philadelphia, hold, 
on the contrary, that rickets is much more common in Europe than 
in this country. As Gee finds that the proportion of " SO'S per cent, 
of sick children under two years of age were rickety," and as the 
proportion for the principal cities of Germany is 25 per cent, for 
Dresden, 13*4 per cent, for Prague, and 11 '1 per cent, for Berlin, this 
country is rather to be compared with England. f It seems to the 

*" The American Journal of the Medical Sciences," January, 18'72, "Observations 
on the Frequency and Symptoms of Rachitis," etc., by John S. Parry, M.D., etc. 
f Senator, in Ziemssen's " Cyclopaedia," vol. xvi, article " Rickets." 



910 



DISORDERS OF NUTRITION. 



author that Dr. Parry's estimate is much too high for this country as 
a whole, although it may have been correct for the limited area of his 
observation. The disease, although more prevalent among the chil- 
dren of the squalid poor, also occurs among the well-to-do classes. 
Certain bodily states of the parents may exert a very baleful influence 
on the constitutions of their offspring, of which rickets may be regarded 
as an example. An innate tendency to rickets is a result of marriages 
of consanguinity, or of those too old, or of the feeble and cachectic. 
While Sir William Jenner holds that rickets is not inherited, he strongly 
insists on the influence of the health of the mother on the development 
of rickets in the child.* All the causes of every kind, which depress 
the bodily powers of the mother, increase the tendency to the produc- 
tion of rickety children. While the bodily condition of the mother is 
much more intimately concerned than that of the father, the effect of 
any given cachexia is much more certain and disastrous when both 
parents are affected. The rickety constitution may also be inherited. 
Numerous illustrations of this fact have been collected, and it is gen- 
erally admitted by authors, but is denied by Jenner. After birth, the 
hereditary tendency is brought into an active condition by faulty ali- 
mentation and unhygienic surroundings. Rickets also occurs in the 
inferior animals.f The recent observations on "the influence of certain 
specific irritants upon osteoplastic tissue " have thrown great light on 
the production of rickets. These specific irritants are phosphorus and 
lactic acid. If to the action of these, when introduced into the econ- 
omy, is added a deficiency in the amount of lime-salts contained in 
the food, or an inability to appropriate that received, there will be pro- 
duced the state of rickets. Lactic acid is abundantly formed in the 
intestinal canal of the infant, and acts as an irritant of the osteoplas- 
tic tissue, while at the same time it is a solvent of the lime-salts, and 
thus effects their elimination. J; 

Pathological Anatomy. — The distinctive lesion of rickets is a pecu- 
liar alteration of the osseous tissue of the body. The long bones are 
thickened at their epiphyseal extremity ; the bones generally are soft- 
ened, the flat bones are thickened ; various deformities result from 
the action of mechanical causes, as, for example, deformities of the 
chest, distorted spine, bent legs, etc. ; arrest of growth, not only of the 
bones themselves, but of all associated parts ; related lesions in the 
pericardium, lungs, and capsule of the spleen ; and morbid alterations 
in the nutrition of the brain, spleen, liver, lymphatic glands, and mus- 
cles, etc. (Jenner). Besides these changes, the bones are found in a 

* "Medical Times and Gazette," May 12, 1860, "A Series of Three Lectures on 
Rickets." 

f " Die Rachitis bei Hunden," von Dr. W. Schiitz, Yirchow's " Archiv," Band xlvi, 
s 350. 

J Senator, op. cit. 



RICKETS. 911 

highly hypersemic condition, which extends to the periosteum, sub- 
periosteal tissue, and the medulla. The most characteristic changes 
are those occurring at the junction of the epiphysis with the diaphysis. 
Calcification of the proliferating cartilage corpuscles goes on irregu- 
larly, and the medullary spaces extend beyond the line of calcification. 
Hence the epiphysis contains cartilage irregularly interspersed in the 
ossified portions, and the medullary spaces are irregularly bordered by 
cartilage and by bone. The periosteum is equally changed. Besides an 
intense hypersemia, already mentioned, this membrane is much thick- 
ened, closely adherent to the bone, and its cellular elements, rapidly 
proliferating, are being converted into bone-cells. When flat bones 
are cut across, they are seen to be highly congested, and present a 
reticulated structure under the periosteum (Senator). The result of 
these changes is, that the bones are so soft that they can be easily cut, 
and bent with a slight force. Chemical examination has disclosed im- 
portant changes.* When the disease is far advanced, the animal mat- 
ter does not furnish chondrin or gelatin, and gluten has been obtained 
from it. Jenner finds that while the bones of healthy children yield 
thirty-seven parts of animal and sixty-three of mineral substances, the 
bones of rickety children yield about seventy -nine parts of animal and 
twenty-one parts of mineral matter. Besides the alterations of bone, 
which are essential, there occur lesions in other organs, some of which 
are accidental, as the intercurrent diseases ; and others seem to have 
the relation of effect, as chronic diarrhoea, enlarged mesenteric glands, 
fatty degeneration of the liver, and enlarged spleen. 

Symptoms. — Rickets begins during the intra-uterine life, and the 
characteristic changes have been recognized in the foetus. The usual 
period of its first symptoms is from the fourth to the seventh month. 
It is a disease of early life. The cases occurring within the first and 
second year greatly exceed all of the subsequent life. When the 
initial symptoms begin, there is a period of several months during 
which the nature of the case may remain in doubt. The first symp- 
toms are connected with the organs of digestion, and are such as may 
arise during the course of many chronic diseases. It is observed that 
the child wastes, but this change is attributed to indigestion, there 
being more or less diarrhoea and vomiting, the stools and the matters 
vomited having an acid reaction. The stools are also light in color, 
because of the absence of bile, and have an odor of decomposition. 
The appetite is wanting entirely, or is capricious, and vomiting is fre- 
quent. Besides wasting, the child grows dull, listless, and peevish ; 
there is some fever present, and intense thirst is experienced, the child 
swallowing enormous quantities of water. If the child has begun to 
walk, it soon becomes too feeble, and prefers to sit or lie quietly, and 

* " Ueber Osteomalachia und Rachitis," von Dr. F. Ruloff in Halle, Yirchow's " Archiv," 
Band sxxvii, s. 433. 



912 



DISORDERS or NUTRITION. 



is equally indisposed to any exertion as to any amusement. Pains in 
the limbs, especially about the joints, are complained of. The pulse 
is quick and irritable, and the superficial veins are swollen. The ante- 
rior fontanelle remains open and does not diminish in area. These 
symptoms do not indicate the nature of the disorder which is now de- 
veloping, but certain signs of high significance make their appearance 
after a variable period of intestinal troubles and impaired nutrition. 
To Sir William Jenner we owe the credit of having emphasized the 
importance of these symptoms. The first is profuse perspirations of 
the head, neck, and upper part of the chest, appearing chiefly while 
the child is asleep, but at the same time the abdomen and extremities 
are dry and hot. The next symptom is a feeling of burning heat, 
especially in the lower limbs, impelling the child to kick off the cov- 
ering and keep the legs exposed to the external air in cold weather. 
The third symptom is tenderness of the whole body. The rickety 
child does not play and toss its limbs about in all directions, but it 
keeps as motionless as possible, and cries out when it is taken up, or 
moved, or pressed on. At this period, also, the urine is abundant, and 
deposits a copious sediment of the lime salts. The child at this period 
begins to have a peculiar, a characteristic appearance. It is languid, 
wasted, its countenance wearied, depressed, and aged, the face has 
grown broad and square, the hair is thin, dry, and dead, the fontanelle 
is open widely, the muscles are wasted and flabby, and seem unable to 
support the body erect, the head sinks between the shoulders, and the 
abdomen is swollen and protuberant. Now appear the changes in 
the bones which unmistakably indicate the nature of the case. The 
extremities of the long bones swell and have a knobby appearance ; 
they yield to the weight of the body or the action of the muscles and 
bend, those of the lower extremities forward and outward and the fe- 
murs forward, and, if the child is walking, outward also. At a more 
advanced age, the curvature of the lower limbs is different ; the knees 
approximate by bending of the femur and tibia in a curve whose con- 
cavity is toward the middle line of the body, and the feet are turned 
away from each other, so that the child walks on the ankle and inner 
side of the foot ; or the bending is in the opposite direction, both 
limbs bent like a bow, the child walking on the outer surface of each 
foot, and the knees widely separated. The spine-curves are determined 
by the child's walking or not walking. In the former, the natural an- 
terior curvature of the cervical spine is greatly exaggerated ; the face 
is turned upward and the head falls back, and if the muscles are very 
weak the head is not supported by the neck-muscles, but flops about 
idly. The other, or posterior curve of the child in arms, commences 
at the first dorsal and extends to the last dorsal. It may be so great 
as to be mistaken for angular curvature, and Jenner proposes to dif- 
ferentiate by simply extending the child ; but, in old cases, the vertebra 



RICKETS. 



913 



and intervertebral disks have undergone permanent changes and can 
not be moved. Lateral and outward curvature of the spine also takes 
place ; but these forms are less common, because those that are usual 
are mere exaggerations of normal curves. Important changes occur 
in the formation of the thorax. The ribs, being softened, yield to the 
atmospheric pressure, the sternum is projected forward, thus increasing 
the antero-posterior diameter of the chest. The ribs are bent poste- 
riorly to an acute angle, and a groove is formed along the junction 
of the ribs with their cartilages, extending from the first to the ninth 
or tenth rib, but farther down on the left side. Owing to the position 
of the heart, the chest-wall of the praecordial space, supported also by 
the liver, spleen, and stomach, does not recede and hence is appar- 
ently more protuberant. Similar curves occur in the upper extremities, 
but they are determined by the age and the muscular actions imposed on 
these members. The head of the rickety child appears larger than that 
of a healthy child of the same age ; but this is only apparent and not 
real, the difference being due to the wasting of the face and neck in 
the former. If the rickety child is under two years, the fontanelle, 
which normally closes by this time, is widely open, and remains open 
till the third year or longer. The vertex has a flat shape, the forehead 
is large and square, and the parietal bones are expanded. The bones 
of the face — the upper jaw and the malar — cease to grow, while the 
frontal and ethmoidal sinuses expand, and hence the greater prominence 
of the latter. The process of dentition is either delayed, or it is en- 
tirely arrested, or the teeth, if formed, decay and fall out.* The pel- 
vis, as the chest, acted on by the weight of the body and by the 
muscles attached to it, is deformed in various ways. The sacrum and 
pubis may be approximated, or the iliac bones may be distorted in- 
wardly, or the outlet may be changed in form and narrowed by the 
sacrum bending forward. The gastro-intestinal disorders, which pre- 
cede the osseous changes, continue during the development of the 
latter. Emaciation goes on at the same rate, the abdomen enlarges 
still more, the muscles waste and grow weaker, there is less and less 
disposition to voluntary exertion, the perspirations are more free, the 
thirst increases, the bowels become more irregular and the evacuations 
more unhealthy, containing little or no bile, are fetid, the food often 
passing unchanged. The pains in the bones increase in severity, and 
their growth ceases entirely. Progressing in this way, after a variable 
period, the case is terminated by some intercurrent malady, or by the 
development of some one of its natural sequelae, or by restoration to 
health. 

Course, Duration, and Termination —Cases of rickets of so acute a 
character as to run through their course in a few weeks have been de- 

* Dr. Samuel Gee, '* St. Bartholomew's Hospital Reports," vol. iv, 1868, p. 69, " On 
Rickets." He gives the case of a boy of three years, who had cut only eight teeth. 
60 



914 



DISORDERS OF NUTRITION. 



scribed. In its ordinary form, rickets is an essentially chronic mal- 
ady, and lasts from months to years, often many years. When the 
disease begins very early, the changes are more extensive and severe ; 
but those cases are more slow in progress which begin during or sub- 
sequent to the second year, and they are hindered in growth by more 
or less prolonged periods of improvement, during which the bone 
affection subsides and the intestinal disorders cease for the time, to 
be resumed when the exacerbations come on. Those cases beginning 
after the first dentition pursue a milder course, and, if properly man- 
aged, end in recovery, but with the deformities and arrested growth 
of the period of the disease at which arrest occurred. Recovery may 
take place in those cases occurring the first year of life. When such 
a favorable course is to be pursued, the teeth, which had been tardy 
in making their appearance, come through and do not decay, the swell- 
ing of the bones subsides, the appetite improves, and the nutrition be- 
comes more active. Various complications arise. Among the most 
common are catarrh of the bronchial tubes, broncho-pneumonia, capil- 
lary bronchitis, congestion of the lungs, and pleural effusion. Jenner 
strongly insists on the dependence of laryngismus stridulus on rickets, 
or a rickety constitution. The gravity of slight affections of the tho- 
racic organs is much increased because of the diminished capacity of 
the thorax. Enlarged spleen is present in two thirds of the cases prov- 
ing fatal. Enlarged lymphatics also may be associated with it, and 
important changes in the blood take place, a very severe anaemia re- 
sulting. Chronic hydrocephalus may also occur as a complication, 
and death is not unfrequently caused by convulsions. Protracted 
diarrhcea, ulceration of the intestine, and amyloid degeneration of or- 
gans, may also appear during the course of unfavorable cases. 

Diagnosis. — When rickets is fully developed, a question of diagnosis 
can scarcely arise. The only disease with which it may be confounded 
is inherited syphilis. Rickets does not appear, as does syphilis, during 
the first days of life. The " snuffles " and cutaneous lesions do not be- 
long to rickets ; enlargement of the epiphyses of the long bones does 
not belong to syphilis. Local deformities, which may simulate the 
changes wrought by rickets, are distinguished by the fact that the lat- 
ter are general and not local. 

Treatment. — The most important remedies for rickets are hygienical 
and dietetic. Good air, warm clothing, daily bathing, and a nutri- 
tious diet, are essential. If the child is nursing, the milk of the mother 
should be carefully examined. If she is the subject of syphilitic in- 
fection, or of a cachexia, the child should be removed, although the 
milk may seem to be entirely healthy. No rickety child should be 
" raised by hand," if practicable to avoid it. If, however, it can not 
be nursed, a proper diet becomes then a subject of high importance. 
Good cow's milk, diluted by one third to one fourth of lime-water, is 



LYMPHADENOMA. 



915 



the most suitable aliment. In the absence of this, condensed milk may 
be substituted. Should these disagree, as shown by the passage of a 
great deal of casein in the evacuations, barley-water with one fourth 
cream added is an excellent substitute. The various substitutes for 
mother's milk or infant food, offered for sale, are of doubtful propriety, 
since they usually contain an excess of starchy food, or are prepared 
on false principles, or based on theory. The points to which medici- 
nal treatment should be directed are the disorders of digestion, the 
acidity of the evacuations, the absence of bile, and the waste of the 
lime salts. Lime-water should be given freely with the milk, or car- 
bonate of lime in small quantity may be stirred in the milk. Pepsin 
in full doses is highly serviceable, and, if there are vomiting and diar- 
rhoea, it may be given with bismuth. Pepsin, with diluted muriatic 
acid in small quantity, is also useful, the acid acting the part of an 
anti-ferment, and preventing the formation of lactic acid.. Brandy, 
re enforced as to its astringency by a few drops of tincture of catechu, 
is a most efficient remedy also, both to counteract the depression and 
to act as an anti-ferment and an astringent. Cod-liver oil is the most 
efficient remedy against the constitutional condition. Moreover, cod- 
liver oil improves the digestion and changes the character of the evac- 
uations. It may be given in an emulsion with lime. The dose should 
not exceed half a drachm to one drachm, three times a day, but it 
should be kept up faithfully for a long time. Small doses of iron, the 
carbonate saccharated, the most easily digested, or the acetated tinc- 
ture, or the bitter wine of iron, should be persistently administered. 

LYMPHADENOMA. 

Definition. — By lymphadenoma is meant a dyscrasic affection, char- 
acterized by enlargement of the lymphatic glands and of the spleen, 
and by progressive anasmia. It is also called HodgMri's disease, be- 
cause it was first described by Dr. Hodgkin in 1832,* and is known as 
" malignant lymphoma," " lympho -sarcoma," the name given it by Vir- 
chow, and " pseudo-lukemia," as named by Cohnheim. 

Causes. — Little is known as to the influences producing the disease. 
It is not hereditary ; it may come on without obvious cause in an in- 
dividual in apparently perfect health ; it is three times as frequent in 
males as in females, and is more common in youth and old age than in 
the middle period of manhood, but it may occur at any age. 

Pathological Anatomy. — The changes peculiar to this disease are 
found in the lymphatics and in the spleen. In advanced cases, all the 
glands of the body, superficial and deep, are diseased, and the adenoid 

* " Medico-Chirurgical Transactions," vol. xvii, 1832, p. 68, '* On some Morbid Ap- 
pearances of the Absorbent Glands and Spleen," by Dr. Ilodgkin, presented by Dr. R. 
Lee, read January 10 and 24, 1832. 



916 



DISOKDEBS OF NUTEITION. 



tissue in t"he course of the lymphatic vessels takes on an overgrowth. 
The cervical, axillary, inguinal, retro-peritoneal, bronchial, mediastinal, 
and mesenteric are in turn affected, and in the order named. Usually 
both sides, but sometimes only one side, is affected. The size of the 
glands affected ranges from a filbert to a hen's-egg, and when a group 
of glands is enlarged to the maximum the whole collection forms 
an immense tumor, which may have the dimensions of a child's head. 
At first each gland is separate and freely movable ; at length the 
whole group forms a solid mass ; but other glands in other situations 
may still remain mobile. The growth may ultimately penetrate the 
capsule and extend into surrounding tissues, and may even perforate a 
vessel. The solidification of a group of glands is also brought about 
by inflammation of the surrounding connective tissue. The pressure 
of the enlarging glands may cause atrophy of neighboring structures 
and interfere with the functions of organs. Two kinds of changes are 
noted in the glands : some are hard and others soft, but those which 
have been soft may become hard. Sometimes it is the large, some- 
times the small, glands that are hard. On section of an affected gland, 
the difference between cortical and medullary parts has disappeared ; 
the color is whitish or grayish, with here and there a spot of hyperae- 
mia. The soft glands contain a great quantity of lymph-corpuscles 
(or cells strongly resembling them), which gradually displace the septa 
of the gland, and thus give to its cut surface an homogeneous appear- 
ance. In the harder glands, the firmness of structure is due to the 
development of fibroid tissue, which takes place in the septa, in the 
reticulum, and in the walls of the capillary vessels. Finally, the cells 
atrophy and disappear before this growth of fibrous tissue. The spleen 
is enlarged in three fourths of the cases, but slightly enlarged in many 
of these, the increase in size being due to simple hypertrophy in a few 
instances, and to disseminated growths in the majority. These growths 
may be the size of peas, distributed through the organ, or may occur 
in larger nodules, looking like suet, as Hodgkin was the first to say. 
These masses are not inclosed in a capsule, but are surrounded by com- 
pressed splenic pulp. They do not often pierce the capsule of the 
spleen, but, if large and numerous, do compress the splenic pulp, which 
atrophies.* These splenic growths correspond closely with the growths 
in the lymphatic glands, and consist of the same cells and fibroid tis- 
sue ; and infarctions are also encountered, f In some cases, the mar- 
row of bones has undergone changes ; it becomes converted into a 
reddish-gray, soft, almost fluid material, due to the predominance of 
lymphoid cells, and other and larger cells, with compound nuclei. This 
alteration of the marrow of bones is not unlike that which occurs in 

* Virchow, "Die Krankhaften Geschwiilste," zweiter Band, s. 735, Fig. 203. 
f Langhaus, Virchow's " Arcliiv," Band liv, s. 512. 



LYMPHADEXOMA. 



917 



leucocythemia. The large follicles at the base of the tongue enlarge 
to a considerable extent, and the adenoid tissue of the intestinal mu- 
cous membrane and of the tonsils takes on the same kind of change as 
the lymphatic glands. One tonsil may ulcerate, while the other is 
enormously enlarged. The changes occurring in the adenoid tissue of 
the solitary glands and of Peyer's patches may result in great thick- 
ening of the intestine walls, but do not encroach on the lumen of the 
bowel.* The liver is invaded in a considerable proportion of the 
cases by minute lymj^hoid growths, varying in size from a pin-head to 
a pea, and having the same composition as those of the spleen. In 
other cases the adenoid tissue is not disseminated in isolated masses, 
but accompanies the portal vessels occupying the interlobular spaces, 
and sending processes into the acini. One third of the liver may 
be thus occupied, f Fatty degeneration may coincide with the lym- 
phoid disease in the liver, adenoid growths occur in the kidneys also, 
and chiefly in the cortex. The growths are of small size — from a pin's- 
head to a pea — and are disseminated in the inter-tubular spaces. They 
cause atrophy by pressure, and initiate parenchymatous degeneration 
with the usual consequences. The same growths are rarely found in 
the ovaries and testes, and often in the thymus. The lungs may be 
attacked by contiguity of tissue from the diseased bronchial glands, or 
by the vessels. The growths found in the lungs are small, grayish, 
and firm, and are often mistaken for tubercles (GowersJ). More or 
less effusion occurs in the thorax, and sometimes, but rarely, lymphoid 
growths are found in the sub-pleural tissue, and in the substance of 
the diaphragm. Sometimes the heart is small ; again it is far advanced 
in fatty degeneration ; only rarely have the characteristic adenoid 
growths been detected in the substance of the organ. Murchison § 
records an adenoid growth of the dura mater above the foramen mag- 
num, and Mosler one above the foramen opticum. 

Symptoms. — There are two groups of symptoms : those due to the 
disease, per se j those due to the interference by the growths in the 
functions of various organs. As regards the first group there are two 
distinctive symptoms — the enlarged glands, and the anaemia. The cer- 
vical lymphatic glands are, in a majority of cases, the first to enlarge, 
and the others, as a rule, follow in the order which has been already 
given. In a few instances a febrile attack accompanied the initial trou- 

* Moxon, "Transactions of the Pathological Society," 1873, p. 101. Murchison had 
made the same observation in a case of the same kind, "Pathological Transactions," 1870. 

f Wilks, "Guy's Hospital Reports," 1865, "Cases of Lardaceous Disease and Allied 
Affections," p. 128, "Peculiar Enlargement of the Lymphatic Glands." 

X Dr. "W. R. Gowers, Reynolds's " System," vol. iii, American edition, article " Hodg- 
kin's Disease." The author has to express his indebtedness to this elaborate and exhaus. 
tive memoir for valuable information. 

§ " Transactions of the Pathological Society," 1870, p. 3T2. A full history of the dis- 
ease follows. 



918 



DISORDERS OF NUTRITION. 



ble in the glands ; in other cases the irritation of some glands, tempora- 
rily and from trivial causes enlarged, has led to the development of the 
general disease, but some kind of predisposition must have existed. 
The enlarged glands are firm or soft, and are painless unless nerves 
are pressed on. Anaemia may begin and be considerably advanced 
before the glandular enlargements, but it usually succeeds to them. 
The anaemia of lymphadenoma is like the anaemia of any cachexia. 
The functions generally are depressed, and we have, in addition, the 
weak heart, the breathlessness on exertion, and the pallor and feebleness 
belonging to this state. The number of white corpuscles in the blood 
is not in excess of the normal in the majority of cases, and is never 
considerably above normal in any case. The white-blood corpuscles 
are small, as a rule, and vary in size. The red corpuscles are reduced 
in number, and in some cases the number of small red corpuscles is 
large. According to Gowers, the red corpuscles, as counted by means 
of the hgemacytometer, may descend to sixty per cent, of the normal 
in a subject having still some color. Fever occurs in about two thirds 
(Gowers) of the whole number of cases. Fever may be present, also, 
as a symptom of some intercurrent febrile affection ; but it is a part 
of the morbid process in young subjects. Although the course of the 
fever is irregular, three types are known : a continuous type with 
slight diurnal variations ; a remittent fever, hectic in character ; and 
a paroxysmal fever, with intermissions of entire cessation of fever for 
several days. The symptoms due to pressure are as various as the 
organs pressed on. The enlarging cervical glands and thyroid press 
on the carotids and jugulars, interfere with the intra-cranial circulation, 
producing at one time cerebral anaemia, at another time passive cere- 
bral congestion. Deglutition may be interfered with by pressure on the 
pharynx and oesophagus, voice and breathing by pressure on the larynx 
and trachea. The glandular swellings in the chest produce all the 
symptoms of intra-thoracic tumors, by pressure on the cardiac branches 
of the sympathetic, on the recurrent laryngeal, on the pneumogastric 
and phrenic, on the great venous trunks, on the arteries, and on the 
trachea, bronchi, and oesophagus. Within the abdomen these tumors 
may compress the aorta and give rise to the symptoms of aneurism, 
the stomach, and cause nausea and vomiting, the portal vein and he- 
patic duct, and induce ascites and jaundice, the principal nerves, and 
arouse pain, and the great veins, producing oedema of the lower ex- 
tremities. To enumerate all the symptoms which may be excited by 
the pressure of these enlarged glands would be to summarize the symp- 
toms which may be expressed by any disordered organ. 

Course, Duration, and Termination.— The course of lymphadenoma is 
chronic. The average duration of fifty cases collected by Gowers was 
nineteen months; of eighteen cases, the duration was less than one year; 
of fifteen cases, between one and two years. In the only case which 



LYMPHADENOMA. 



919 



the author has had in his own charge, the duration was two years. 
In all cases the initial glandular enlargement — cervical usually — is 
followed after a certain interval by the general affection of all the 
glands. There may be quite an interval, sometimes years, however, 
between the local and systemic affection. The course of the disease 
may be influenced by complications. The anaemia may induce various 
acute inflammations — erysipelas, superficial abscesses, etc. Phthisis 
may occur, as in the author's case. Death is usually due to exhaustion, 
but it may be caused by pressure on the trachea and asphyxia, on the 
oesophagus and starvation, on the jugular veins, carotids, and convul- 
sions and' coma. Certain intercurrent affections may cause death, as 
pneumonia, oedema of the lungs, pleuritic effusions, etc. 

Diagnosis. — The maladies with which Hodgkin's disease may be 
confounded are leucocythemia, with splenic and glandular changes, 
and scrofula. In splenic, glandular leucocythemia the changes in 
the glands succeed to those in the blood, whereas the glandular en- 
largement is the initial fact in lymphadenoma ; and, further, in the 
latter, the relative proportion of white corpuscles is not increased in 
the majority of cases. From scrofula the distinction is made by the 
number, extent, and volume of the glands in lymphadenoma, by the 
extension of the enlarged glands over the body, by their permanence, 
by the anemia, and by the pressure symptoms which affect so many 
organs. In scrofula the enlarged glands are found in one situation, 
and usually about the neck they suppurate ; the symptoms are limited 
to the affected part, and there is neither anaemia nor pressure symptoms. 

Treatment. — Recent experiences by Billroth and Czerny * have de- 
monstrated the curability of lymphadenoma by the internal and par- 
enchymatous use of arsenic. Fowler's solution is usually employed, 
the dose by the stomach being increased to ten, fifteen, or twenty 
minims, thrice daily, according to the forbearance of this organ, and 
from one to five minims in distilled water injected into the enlarged 
glands. Wunderlich has reported a case improved under the use of 
iodide of potassium. The sirup of the iodides of iron and manganese 
has seemed to do good by improving the cachexia. Cod-liver oil is 
certainly useful as a nutrient and tonic, but it can not be regarded as 
curative. Electrolysis has been much commended, but thus far no 
successful cases have been reported. It is obvious that this plan of 
treatment could only be used in the case of the first enlarged glands. 
Extirpation of the diseased glands, when but few are affected, has 
been done, but, as great uncertainty must exist in regard to the nature 
of the malady and the relation of those glands first attacked to the 
subsequent development, the surgical operation can not be considered 
a desirable expedient. 

* " Wien med. Wochenschr.," No. 2, 1881. 



920 



DISORDERS OF NUTRITION. 



ACUTE RHEUMATISM. 

Definition. — Acute rheumatism is a constitutional disease charac- 
terized by fever, inflammation of the joints occurring in succession, 
and by a tendency to attack the peri- and endocardium. It is fre- 
quently called articular rheumatism, rheumatic fever, polyarthritis 
rheumatica, etc. 

Causes. — The vice of constitution belonging to rheumatism may be 
inherited, but it is not possible to indicate its character.* There are 
three types of bodily conformation in which rheumatism occurs : the 
pale, thin, and anaemic subject ; the robust and vigorous individual 
with an inherited tendency ; and the obese, often given to the consump- 
tion of malt-liquors and having a form of acid indigestion (lactic?). 
Acute rheumatism is most frequent in youth and early manhood, 
rarely occurring before seven and after fifty. It is more frequent in 
men than in women, not because of a greater susceptibility to the dis- 
ease, but because men are more exposed to the influences producing it. 
The liability to the disease is increased by having attacks, and a 
longer interval usually separates the first and second seizures than the 
second and third. On the other hand, the susceptibility to rheuma- 
tism lessens with increase of years. Certain diseases dispose to attacks 
of acute rheumatism : thus during the stage of desquamation of scar- 
let fever, and in the puerperal state, attacks in all respects the same as 
ordinary rheumatic fever may occur. The seasons of greatest preva- 
lence are winter and spring, and the occupations most favorable are 
those in which there is the most frequent exposure to inclement 
weather. Protracted stay in damp apartments, lying between damp 
sheets all night, exposure of the body to cold and wet when in a heated 
and perspiring state, are fruitful causes of attacks, the predisposition 
already existing. The frequency with which rheumatic attacks follow 
exposure to cold, to chilling the superficies of the body, is a very strik- 
ing fact. Senator f ingeniously supposes that the irritation of the 
peripheral fibers of the centripetal nerves excites the vaso-motor and 
trophic centers into abnormal activity. Various facts go to prove 
that a condition of the joints not unlike rheumatism is brought about 
by certain diseases of the spinal cord and injuries of nerves.J As, 
during muscular exercise, lactic acid and the acid potassium phos- 
phate are produced, and as an excess of acid is a fact in rheumatism, 
and, further, as sudden chilling of the body stops the elimination of 
those acid products, which therefore accumulate, there would seem 

* Notwithstanding the agency of a damp climate in causing acute rheumatism, in New 
Mexico, a remarkably dry climate, this disease prevails largely. Indeed, the author saw, 
in 1860, what might be regarded as an epidemic. 

f Ziemssen's " Cyclopaedia," vol. xvi. 

% "Injuries of Nerves and their Consequences," S. Weir Mitchell, op. cit. 



ACUTE RHEUMATISM. 



921 



to be a necessary connection between these states. The agency of lac- 
tic acid in producing rheumatism seems further strengthened by the 
fact, first observed by Richardson, that the injection of lactic acid is 
followed by endocarditis, and its medicinal administration in diabetes 
has in various instances apparently caused a rheumatic inflammation 
of the joints. This chemical theory, originally proposed by Prout and 
supported by Richardson's experiments, has received a severe blow in 
the denial by Reyher ^ that the injection of lactic acid is followed by 
endocarditis, as affirmed by Richardson, or that an accumulation of the 
acid in the blood is a cause of rheumatism, as suggested by Prout. 

Pathological Anatomy. — The changes in the joints are slight as com- 
pared with the apparent extent of the mischief. The synovial mem- 
brane is injected more or less deeply, and the fringes are highly vascu- 
lar. The membrane has lost its pearly transparency and its smooth- 
ness, and is cloudy and granular. The synovial fluid is increased in 
amount and is changed in character. Instead of being a transparent, 
homogeneous, viscid fluid, it is thin, watery, reddish from extravasated 
blood, turbid from the presence of fibrin, and some pus-corpuscles. 
There is never any considerable amount of blood present in the fluid, 
except in the case of the hsemorrhagic diathesis, and the quantity of 
pus is slight unless the rheumatic inflammation is complicated by some 
other malady. A half -century ago much importance was ascribed to 
the excess of fibrin in the blood, to the buffy-coat and to the cupped 
appearance of the clot ; but these features of the blood composition 
are not now considered to have any special significance, besides the 
excess in fibrin. Garrod states that the quantity of fibrin reaches from 
four to six parts per thousand. The serum is alkaline, and is free from 
uric acid and lactic acid. The usual complication of acute rheumatism 
is inflammation of the peri- and endocardium. The nature of the 
pathological changes in these cardiac affections is set forth in the 
articles on these topics. 

Symptoms. — For several days previous to the attack of acute rheu- 
matism, the patient complains of muscular soreness, often of neuralgic 
pains localized in some important nerve ; in other cases the patient ex- 
periences a good deal of pain, stiffness and soreness of certain joints, 
and with these joint- and muscle-pains and soreness are associated an 
impaired appetite, coated, pasty tongue, constipation, etc. The disease 
may begin abruptly without the prodromic symptoms just described, 
by a chill, followed by fever, or by a succession of slight chills with 
fever, the temperature rising to 102,° 103,° or 104° Fahr. There occur 
also, thirst, a coated tongue, anorexia, and constipation ; headache and 
wakefulness are experienced ; and the ankles become painful and can 
not support the body. Examination of the painful joints discloses the 

* " Zur Frage von der Erzengung von Endocarditis durch Milchsaure-injection," etc, 
by Dr. Gustav Reylier, Yirchow's " Archiv," vol. xxi, p. 85. 



922 



DISORDERS OF NUTRITION. 



fact tliat they are tender, hot, swollen, and red, and every attempted 
movement produces exquisite suffering. On the same day, or certainly 
the next day, other joints are affected, and those first attacked get a 
little easier and the swelling slowly subsides. In the first attack the 
larger joints are affected almost entirely, but in succeeding attacks the 
smaller joints, especially of the hands, suffer severely. The joints first 
attacked and getting well may be seized upon again, and in turn most 
of the joints of the body are affected. By the end of the first week, 
a number of joints, six, ten, even twelve, may be inflamed. The 
joints most frequently visited are the ankle and knee ; next, the shoul- 
der, elbow, and wrist ; then the hip and fingers, and finally the spine, 
the toes, and the lower jaw. Even the crico-arytenoid articulation may 
be attacked (Senator). The disease seems to pursue a certain order in 
its visits to the articulations — first touching at the right ankle-joint, 
then flying over to the left, then the right knee is reached, afterward 
the left (Garrod). The suffering imposed by a rheumatic seizure is very 
great in any case, but is the greater the larger and the more numer- 
ous the joints inflamed. When the spine is attacked the pain and in- 
convenience are at the maximum, for no movement of the body can be 
attempted, and even breathing is painful. The position assumed by 
the patient is the easiest which his disability will permit ; the limbs 
are half flexed, the foot turned in a little, and the hand extended, the 
fingers separated more or less widely. So exquisitely tender are the 
joints, in many cases, that the patients manifest uneasiness when any 
one approaches the bed ; the weight of the bedclothes becomes intoler- 
able ; and even the jar of one walking heavily over the floor awakens 
pain. The joints are red and swollen, and sometimes the tendons and 
connective tissue about the. joints are infiltrated and oedematous. On 
the other hand, the joint may have a natural appearance and yet be 
very painful. Even when quite a good deal swollen, the inflammation 
may subside in a few hours, and attack other joints in a corresponding 
way. 

This tendency to migrate from one joint to another is the most 
characteristic feature of acute rheumatism. As the effusion into and 
about the joint is serous, and as, besides this, only a condition of hyper- 
aemia is present, it is not surprising that such sudden transitions take 
place. In the mildest cases, with few joints affected, and without 
complications, the fever is slight, consisting of an exacerbation devel- 
oping toward evening, and entire freedom from any increased body- 
heat the rest of the time. In the decided cases, however, there is fever 
of a somewhat remittent type, the exacerbation coming on in the after- 
noon. The maximum rarely exceeds 104° Fahr., and the usual tem- 
perature is 100° to 101° in the morning and from a half to one degree 
higher in the afternoon. The range of febrile heat is not uniform ; 
besides the daily variations, remissions and even intermissions take 



ACUTE KHEUMATISM. 



923 



place during the course of the disease. If there should occur a com- 
plete intermission, usually there is an exacerbation of all the symptoms 
with the rise of fever. The termination of the febrile movement is 
gradual and not by crisis. N'ow and then a case of remarkable sever* 
ity is encountered. Violent delirium occurs and a state of hyperpy- 
rexia comes on, the temperature rising to 108°, 109°, and even 111° 
Fahr., has been noted,* and the rise continues subsequent to death, 
for a short time. Dr. Ringer observed that this condition came on 
suddenly in three cases who were doing well. Either delirium fol- 
lowed by stupor or stupor without delirium appeared without any 
warning, the temperature rose to 111° in one case, and to 109° and 
110° in the others, and death ensued in all in a few hours. Quincke, 
Wilson Fox, and others have reported similar cases, but they are for- 
tunately rare. Delirium, coma vigil, excitement with very high tem- 
perature, phenomena not unlike one variety of heat-stroke, occur in 
the case of spirit-drinkers or the cachectic attacked by acute rheuma- 
tism. The rate of pulse is not usually conformable to the temperature 
curve, because it is accelerated by other causes — chiefly by the pain. 
There is in acute rheumatism not a hot skin, because of the sweating. 
This free action of the skin is a part of the morbid process ; it occurs 
with the joint affection, and subsides somewhat before the latter, and 
returns with a relapse. The sweat is acid in reaction, and the linen 
and person of the patient have a strong acid odor. The sweat also 
contains urea, and formerly was supposed to owe its acidity to lactic 
acid — a statement which has not been confirmed. As in other dis- 
eases characterized by profuse sweating, sudamina appear on the skin. 
Other eruptions are also sometimes present — urticaria, purpura, her- 
pes, etc. The severe loss by the skin necessarily lessens the quantity 
of urinary water. The urine is concentrated, strongly acid in reac- 
tion, of a deep-red color, and deposits a great quantity of urates and 
uric acid. The chlorides of the urine are diminished, the sulphates 
are increased (Parkes), and the urea is also greater than normal 
in its relative proportion. Albumen is present in the urine in small 
amount. 

Course, Duration, and Termination. — The course of acute rheuma- 
tism is much influenced by complications. The most important com- 
plication is the rheumatic inflammation of the peri- and endocardium, 
and of the cardiac muscle. This sometimes is the first symptom, the 
joint affection appearing subsequently. The author saw in New Mex- 
ico cases of rheumatism pursuing this course. The relative propor- 
tion of heart cases to those having joint lesions only is stated differ- 
ently by different authorities, Bouillaud standing at one extreme with 
fifty per cent., and Chambers at the other with five to seven per 

* Ringer, Dr. Sydney, " On some Fatal Cases of Rheumatic Fever, accompanied by a 
Very High Temperature of the Body," " Medical Times and Gazette," October 5, 1867. 



924 



DISORDERS OF NUTRITION. 



cent.* There can be no doubt tbat great differences exist, and hence no 
numbers can state the true proportion. The inmates of hospitals have a 
greater tendency to heart complication than those sick under favor- 
able conditions at home. The existence, then, of the various diatheses 
and cachexise must exert an unfavorable influence over the course of 
acute rheumatism. Again, youth is a predisposing cause of cardiac 
complication, a fact which Senator f ormularizes as follows : " The 
younger the patient, the greater the risk of his heart becoming af- 
fected." Treatment, according to the exhibit of Dr. Dickinson, exer- 
cises no little influence over the tendency to cardiac complications, if 
rightly directed. Comparatively rare complications are bronchitis 
and pneumonia — the former occurring the more frequently. Pleu- 
risy is still more common because induced by contiguity of tissue, and 
hence of the left side chiefly, although it may be double. These com- 
plicating diseases differ in no material way from the same idiopathic 
affections. Meningitis has rarely occurred, and doubtless, of the cases 
reported, most of them were examples of cerebro-spinal meningitis. 
The natural history of acute rheumatism has been determined thor- 
oughly. The mint-water treatment of Sir William Gull and Dr. Sut- 
ton, and the expectant methods of Garrod and of Flint, have demon- 
strated the course pursued by rheumatism when not interfered with 
by remedies. The disease manifests a tendency to spontaneous cure 
about the thirteenth to the fifteenth day, and still more decidedly 
from the fifteenth to the twenty-first day. The average stay of rheu- 
matic patients in Guy's Hospital, when subjected to the " mint-water 
treatment," was for males 2T'6 days, and for females 26*8 days.f The 
conclusions arrived at by the advocates of non-intervention have been 
severely contested by Dr. Fuller and others. In almost the last paper 
written by the late Dr. Fuller,]; he has demonstrated the fallacy under- 
lying the observations of the Guy's Hospital clinicians, and has proved 
the immense superiority of the so-called alkaline treatment. Notwith- 
standing the disease may be classed with the self -limited, its course is 
materially abbreviated not only by the alkaline, but by other methods 
of treatment. The acute stage of a rheumatic seizure, if the first one, 
is not often terminated in an earlier j^eriod than two weeks, and is 
more frequently prolonged to three or even four weeks. After the first, 
the subsequent attacks are usually less severe, and the acute symptoms 
terminate in one to two weeks, and may be prolonged to three. The 
duration is, however, materially affected, not only by the complications 

* But Dr. Fuller, in his " Treatise on Rheumatism," puts the proportion of heart 
complications at one third, after examination of many statistics (third edition, pp. 258- 
284). 

f "Guy's Hospital Reports" for 1865, "Cases of Rheumatic Fever, treated for the 
most part with Mint-Water," collected from Dr. Gull's case-books by Dr. Sutton. 
X "The Practitioner," vol. ii, p. 129. 



ACUTE RHEUMATISM. 



925 



mentioned above and by the treatment, but by the number of joints vis- 
ited. If more than six joints are visited, the duration of the acute 
symptoms will not be less than two to three weeks ; and, if a dozen 
joints are one after another brought within the diseased circuit, the 
duration will be scarcely less than the traditional six weeks. So many 
factors, therefore, are concerned, that results must be very uncer- 
tain which are arrived at Tyithout estimating the value of all. Rheu- 
matism is by no means a serious disease if judged from the standpoint 
of its immediate effects, but it becomes more formidable when the 
cardiac and other complications arise. The mortality from rheuma- 
tism alone does not exceed three per cent. ; but the after-consequences 
of the cardiac lesions are responsible for a great many more deaths. 
When death occurs during the seizure, it is determined by the condi- 
tion of hyperpyrexia with delirium most frequently, and alcoholic ex- 
cess is probably the real cause of this accident in most cases, l^ow 
and then a fatal result may be due to meningitis, but more frequently 
to peri- and endocarditis, with myocarditis. In a very small propor- 
tion of cases joints may be permanently damaged by thickenings and 
deposits, and slow chronic synovitis. 

Diagnosis. — A well-developed acute rheumatism can hardly be mis- 
taken for any other disease, but there may be difficulty in differentiat- 
ing it from pysemia, rheumatoid arthritis, acute general gout, urethral 
rheumatism, and hysterical joint. Pyaemia differs from acute rheuma- 
tism in the tyj^e of fever, the periodical sweats, the jaundice, the pros- 
tration, and the suppuration and disorganization of joints. Acute 
rheumatoid arthritis is stationary, and is free from constitutional dis- 
turbance, from sweats, and from cardiac lesions. From acute general 
gout it is distinguished by the fever, the sweats, and the cardiac mis- 
chief. Urethral rheumatism attacks one joint, the ankle or wrist, 
most usually, does not migrate, is slower to recover, is unaccompanied 
by fever, and is coincident with a urethral discharge. Hysterical joint 
is without swelling or change of temperature, is exquisitely sensitive 
when the attention is fixed on it, and can be handled even roughly 
when the attention is directed to other objects, and is accompanied 
with other hysterical manifestations. 

Treatment. — Opinions are still greatly divided as to the best treat- 
ment of acute rheumatism. As controversial discussions do not enter 
into the scope of this work, the author confines himself to the expres- 
sion of his convictions. The alkaline treatment has been a real and 
important advance, but the general conception of what is meant by it 
is singularly cloudy. Senator gravely proposes the use of the soda- 
salts because of the supposed toxic effects of the potash-salts on the 
heart. " By the alkaline treatment," says Dr. Fuller, " I mean a plan 
of treatment in which alkalies play an important part, but which con- 
sists not only in the administration of alkalies, but in the careful regu- 



926 



DISORDERS OF NUTRITION. 



lation of the secretions, the strictest attention to diet, and the admin- 
istration of tonics, such as quinine and bark, as soon as the patient can 
bear them." In the treatment by alkalies, the object to be accom- 
plished is, to effect the alkalinization of the secretions, and any result 
less than this will prove a failure. Fuller gives not less than an ounce 
and a half of the alkaline carbonates, either alone or in combination 
with a vegetable acid, during the first twejity-four hours of the treat- 
ment. Two drachms of bicarbonate of potassium are given in a state 
of effervescence by means of an ounce of lemon-juice, or a half-drachm 
of citric acid, in four ounces of water, every three or four hours. If 
the bowels are torpid, as is usual, two compound cathartic pills are 
administered. If the urine no longer exhibits an acid reaction after 
twenty-four to thirty-six hours, the quantity of alkali is diminished 
one half. If the urine continues alkaline at the end of another twenty- 
four hours, three drachms of alkali only are given for the next twenty- 
four hours ; and on the fourth day, if the alkalinity of the urine per- 
sists, the form of the medicine is changed, and a tonic is added to the 
alkali, giving three grains of quinine with a half -drachm of potassium 
bicarbonate three times a day. Aperients are given as required, and 
opium as little as possible, and only when there is excessive irritability. 
The diet is restricted to milk, beef-tea, or broths, barley-water, etc., 
and under no circumstances solid food until the tongue is clean and 
convalescence established. The patient is kept between sheets rather 
cool, and the heaping up of extra blankets on the bed is not permitted. 
^Ye have been thus full and minute in describing Dr. Fuller's method, 
from a conviction of its great value in appropriate cases. It relieves 
the pain quite speedily, shortens the duration and lessens the violence 
of the disease and prevents heart complications. The average dura- 
tion of the cases thus treated is put by Dr. Fuller at eleve7i days. Of 
439 cases subjected to this plan there was not a fatal case ; only a lit- 
tle over two per cent, suffered with a cardiac complication. Dr. Dick- 
inson's statistics are not less striking. Of 161 cases, 113 were subject- 
ed to some other than alkaline treatment, and in thirty-five, or 30*8 per 
cent., the heart became involved ; while only one of forty-eight cases 
treated with alkalies so suffered.* In the pale, feeble, and anaemic 
young subjects attacked with acute rheumatism, alkalies are as a rule 
too depressing, and are followed by a tedious and protracted conva- 
lescence. In this class of cases we possess a valuable resource in the 
tinctura ferri chloridi, first proposed by Dr. Russell Reynolds. This 
remedy must be given in full doses well diluted with water ( 3 ss. of 
the tincture to six ounces of water taken through a glass tube every 
four hours). It has a most favorable influence over the progress of 
these cases, and, as Dr. Anstie pointed out, is very effective as a pro- 

* London " Lancet," January 23 and 30, and February 6, ISVQ, 



ACUTE RHEUMATISM. 



927 



phylactic against the disease when an attack is impending. For the 
acute rheumatism succeeding to scarlet fever, to puerperal fever, etc., 
it is especially desirable and successful. At the present time no rem-, 
edj is so universally employed in the treatment of rheumatism as sali- 
cylic acid in various forms. The success which attends its use is on 
the whole remarkable. Kow that the enthusiasm which first followed 
its use in rheumatism has subsided somewhat, a fair estimate of its 
powers can be made. As it causes very great depression of the heart, 
and excites irritation of the stomach, its utility is much more limited 
than was at first supposed. Furthermore, although its action is very 
prompt, relieving the principal symptoms of the disease in two or three 
days, the tendency to relapses is very great. In a recent paper by Dr. 
Greenhow,* we find a most able exposition of the effects and real util' 
ity of the salicylates. He finds with others that great immediate 
relief follows the administration of these remedies, that the tempera- 
ture declines and with it the pain, but serious toxic phenomena often 
ensue, and relapses occur. Moreover, the drug in considerable doses 
depresses the heart, obliterates the first sound, and causes vomiting, 
tinnitus, hallucinations, etc. Salicin, salicylate of soda, and salicylic 
acid, to be effective, must be given in sufficient quantity to lower the 
temperature — a half -drachm of salicylate of sodium every four hours, 
until the pulse and temperature decline, may be taken as the standard. 
When the pain and fever subside, the dose may be reduced to a scruple. 
In the discussion which followed the reading of Dr. Greenhow's paper, 
the speakers insisted on the persistent use of the remedy to prevent 
relapses. As the effects of salicylic acid and its congeners are decided- 
ly spoliative, the patient is left in a weak and anaemic state. It is good 
practice, according to the author's experience, to give the muriated 
tincture of iron as soon as the reduction of heat and pain is effected, 
while smaller doses of the salicylates are continued. Dr. Greenhow 
finds that the blister-treatment is quite as successful as the treatment 
by salicylates, and open to less objection. The blister-treatment as 
revived by Dr. Davies, of the London Hospital, consists in the appli- 
cation of armlets, wristlets, and fingerlets of blistering-plaster about 
the inflamed joint, but not on it, as carried out by Dr. Dechilly. The 
author has ascertained that an investment of the joint by small blis- 
ters, leaving space between them all around the joint for succeeding 
applications, is a good method. Blisters relieve the pain remarkably, 
chano-e the reaction of the urine from acid to neutral or alkaline, and 
prevent complications. With blisters may be combined the excel- 
lences of the other plans of treatment. The alkaline treatment is par- 
ticularly applicable to " the obese, florid, but flabby drinkers of malt- 
liquors " ; the iron-treatment to the pale, delicate, and anaemic young 

* The London " Lancet," May 29, 1880, " Cases of Rheumatic Fever treated with 
Salicylate of Soda," " Transactions of the Clinical Society." 



928 



DISOEDERS OF NUTRITION. 



subject ; and tlie salicylic treatment to the vigorous, able-bodied sub- 
jects of the inherited tendency or rheumatic diathesis, while blisters may 
be, with proper precautions, utilized in all forms of the disease and com- 
bined with any plan. The complications of acute rheumatism are to 
be treated according to their character. The most important, because 
so rapidly fatal, is the condition of hyperpyrexia with coma. Since the 
remarkable efficiency of the cold bath has been ascertained, better 
results are had from the treatment of this condition than ever before. 
Quiet and rest are of great importance. Solid food must not be given 
the patient until the tongue is clean and the digestion active. Milk^ 
above all things, is the most suitable article of diet. 

CHRONIC RHEUMATISM. 

Definition. — By chronic rheumatism is meant an affection of the 
articulations, characterized by pain and stiffness, with some swelling, 
occurring chiefly after middle life, and influenced by atmospheric 
changes. 

Causes and Pathogeny. — The chronic may succeed to the acute 
form of rheumatism. In all cases of the acute disease the joints 
remain sore and stiff for a short period after the acute symptoms 
have ceased ; but in a few, owing to the constitutional state, to im- 
proper management, too early use of the joints, etc., the articulations 
remain swollen, more or less tender, and disabled. The case may be 
chronic from the first. If the predisposition exist, exposure to cold 
and dampness, working in the water, etc., will develop the disease 
slowly, and those joints undergo alterations first which are most ex- 
posed to injury, and to cold and dampness in the performance of their 
functions. The changes of structure are not well defined in many 
instances, because of the fugitive attacks ; in others, however, there 
are plain evidences of mischief done. The synovial membrane becomes 
cloudy, thickened, and rough, and the cartilages also undergo prolifera- 
tion of their corpuscles and subsequent thickening. Very little effusion 
of fluid occurs into the synovial sac. Fatty degeneration of the artic- 
ular cartilages, erosions of the same, slow changes in the bone, leading 
to induration and thickening, resulting in a limited extent of motion 
of the articulation, are also results of the morbid process. 

Symptoms. — The trouble is limited to the articulations affected and 
to the neighborhood. The joint is swollen more or less, and its move- 
ments are constrained ; it is not red and hot unless some recent inflam- 
matory mischief has been lighted up ; pain is felt in the joint spon- 
taneously, and soreness whenever the joint is moved, and acute pain 
is experienced when there occur changes of temperature and the barom- 
eter is falling. Patients soon learn the indications, afforded by their 
pains, when storms are imminent, or other atmospheric perturbations 



CHRONIC RHEUMATISM. 



929 



The joints are stiff, their movements slow and jerking. As the sheaths 
of the tendons are thickened by deposits, movements cause more or 
less creaking, like rusty machinery, which may be audible. In the 
morning, on rising, movements are particularly slow, rigid, jerking, so 
that dressing is accomplished with difficulty ; use renders them limber 
and supple. Various joints are affected, as a rule, but the disease does 
not migrate from one joint to another ; they may be affected simul- 
taneously or in turn. The muscular pains, which usually accompany 
the joint affection, are due to the extension of the disease to the sheaths 
of the tendons in the neighborhood of the articulations. Myalgia is 
a frequent coincident affection, and hence it is confounded with the 
rheumatism. 

Course, Duration, and Termination. — Chronic rheumatism is a very 
chronic disease. There occur but few changes from month to month. 
Exposure to cold, and especially to cold and dampness combined, in- 
creases the pains and the joint changes ; and warmth — especially re- 
moving to a warm climate — lessens them. Fatigue, manual labor, 
especially in cold and damp situations, and clothing insufficiently 
warm, promote the disease. In forming conclusions as to the future 
course of the malady, these elements must be taken into considera- 
tion. A perfect recovery must be regarded as possible only in those 
cases treated at the outset under favorable hygienic and personal con- 
ditions. When deposits have taken place, and the cartilages and syno- 
vial membrane are changed in structure, a cure can not be effected. In 
old cases tendinous anchylosis may result, and, the muscles wasting, the 
limb will appear much deformed. Chronic rheumatism never causes 
death, nor does it indirectly abridge life except by depriving the pa- 
tient of rest and sleep. 

Treatment. — The remedies intended to assail chronic rheumatism, 
from the constitutional side, are numerous, but they accomplish lit- 
tle. Colchicum, guaiacum, conium, etc., formerly so much employed, 
have no longer any repute as remedies in this disorder. There are, 
however, a few remedies of real value — cod-liver oil, iodide of potas- 
sium, muriate of ammonia, and the lithium salts, notably the bromide. 
Cod-liver oil should be given with a little ether to assist its digestion, 
and in the dose of a teaspoonful three times a day after meals. To 
be of real service, the administration of the oil should continue for 
many months. If there is anaemia, chalybeates should be given. A 
course of iodide of potassium, if the general health of the patient is 
fairly good, often renders important service. It is necessary to give 
it many months, however. Deposits about joints may sometimes be 
absorbed during the administration of muriate of ammonia, but, to 
accomplish anything, prolonged use is necessary. In several cases the 
author has had excellent results from the bromide of lithium. Under 
its use the pains ceased, the swelling subsided, and the suppleness of 
61 



930 



DISORDERS OF NUTRITION. 



the joints was restored. Local applications are highly important. 
Frictions of the affected parts with cod-liver oil, after a general warm 
bath, are an excellent expedient. Warm baths, the Turkish or Russian 
baths, with local douches, are often, but not invariably, highly useful. 
The method of friction and movements, known as massage, is probably 
the best of the local means of treatment. Good results are obtained 
from the baths of the Hot Springs of Arkansas, the warm and hot 
springs of Virginia, the sulphurous waters of the Licks of Kentucky 
and of Saratoga, the Michigan springs, St. Catherine's of Canada, and 
numerous other "resorts" in this country. Mud-baths are also em- 
ployed on a large scale, for the relief of rheumatism and affections of 
the skin, in certain parts of Germany. In chronic rheumatism excel- 
lent results are obtained from the use of galvanism. A current of 
large volume and low intensity should be applied to the affected joints 
to procure absorption of effusions, and the sympathetic ganglia should 
also be brought within the circuit. When galvanism is to be applied, 
the positive pole should be placed over the principal nerve-bundles 
above, and the negative pole brushed over the joint-region. Each 
joint should be taken up in turn, and the applications be faithfully 
made, and the electrical treatment pursued for a long time. 



GOUT— PODAGRA. 

Definition. — By the term gout is meant a constitutional malady, 
inherited, and characterized by the occurrence of paroxysms of - severe 
pain in a small joint — the great-toe usually — due to the presence of 
uric acid in the blood, and the deposit of the urates in the structures 
of the articulation. Podagra is the Latin name for gout in the foot ; 
chiragra, for gout in the hand ; and gonagra, for gout in the knee. 

Causes. — Unquestionably, heredity is the chief etiological factor. 
The causes which rendered the disease hereditary will, of course, pro- 
duce the disease anew in those subjected to their operation. As a 
disorder of the upper classes — of those having wealth, leisure, and 
the opportunity for indulgence in the pleasures of the table — gout has 
had a position of distinction. Sydenham consoled himself for his suf- 
ferings from gout by the reflection that it is an eminently respectable 
disease, by which more rich men than paupers, more wise men than 
fools, are afflicted. But this satisfaction is no longer afforded the vic- 
tims of this malady. Gout is a result of lead-poisoning, and indul- 
gence in the drinking of beer and other malt-liquors, and it therefore 
occupies a more humble position than formerly. Men suffer from at- 
tacks of gout much more frequently than women, and this fact is as 
true of inherited as of acquired gout. It is suggested by Garrod 
(originally by Hippocrates) that the catamenial function acts as a 
safeguard," because, when the inherited tendency exists, the ouu 



GOUT. 



931 



breaks rarely occur until after the menopause. The chief reas>n of 
the comparative exemption enjoyed by women is the difference in 
habits ; when women adopt the meat-eating, and beer- and wine-drink- 
ing habits of men, they suffer the same consequences. Gout begins 
at a comparatively early age, when the bodily predisposition and the 
habits of life favor its appearance. Paroxysms may begin at fifteen, 
but when the disease is acquired they are postponed to thirty-five or 
later. The period of greatest predominance of the affection is from 
thirty-five to sixty-five, and after the latter age it is less and less com- 
mon. The habits of the individual are largely concerned with the 
early production of gout. The drinkers of malt-liquors and wines, 
especially the sweet wines, suffer early. It is the large consumption 
of beer which develops the gouty condition in the laboring classes. 
The excessive consumption of animal food, especially when washed 
down with malt-liquors and wines, is an influential factor. Garrod 
first demonstrated the important fact that lead-poisoning manifests 
itself, in a certain proportion of cases, by paroxysms of gout. This 
statement, at first received with incredulity, is now universally admit- 
ted.* The explanation is, that lead greatly lessens the excretion of 
uric acid, and the proof is afforded in the increased quantity of uric 
acid in the blood. The climate has an effect on the occurrence of the 
seizures, winter being the season of greatest tendency to them, and 
hence they are often avoided by the timely transfer to a warm winter 
locality. 

Pathological Anatomy. — The changes in the joints are characteristic 
when a single joint has been affected, and once only. In such a case 
a part of the head of the metatarsal bone was covered with a white 
incrustation after thirteen years (Garrod). The whole articular sur- 
face of the affected joint attacked is, in severe cases, covered with a 
whitish deposit, to the synovial fringes. First, a transparent fluid is 
exuded into the substance of the cartilage ; the water is absorbed, 
leaving the white incrustation composed of bundles of acicular crystals 
radiating from a center. This material is urate of soda. Most of the 
articulations are, in old and severe cases, more or less affected, but the 
tarsus and carpus and the surfaces of the metatarsal and metacarpal 
bones and some of the phalanges are chiefly diseased. More or less 
urate deposits have been found in the bone itself. The presence of 
this material excites ordinary inflammation, and hence the thickening 
and deformity observed about the diseased joints are partly due to the 
products of inflammation, mixed with the chalk-like accretions of urate 
of soda. The blood also contains urate of soda, and in the perspira- 
tion uric acid is frequently present, and also is in excess in the fluids 
transuded into the pericardium and peritoneum. During the gouty 



* Wilks, Dr. Samuel, "Guy's Hospital Reports," 1869-"70, p. 40. 



932 



DISORDERS OF NUTRITION. 



paroxysm the blood is said to contain an abnormal quantity of fibrin. 
The most important of the changes in internal organs is that disease 
of the kidney known as the " gouty kidney." Crystals of urate of 
soda are deposited in the tubules and inter-tubular tissues, and may be 
seen by the naked eye as white lines. The kidneys are small, granular, 
and fibrous. In the vascular system, atheromatous changes of the se- 
nile type are precipitated by attacks of gout. 

Symptoms. — Acute Gout. — Gout is not always manifested by the 
same signs and symptoms : it may be acute, chronic, or irregular. The 
paroxysm of acute gout may or may not be preceded by prodromic symp- 
toms. In many patients certain symptoms appear invariably, and an- 
nounce the approaching attack. These preliminary symptoms may con- 
sist of gastric disorder — as headache, nausea, a coated tongue, constipa- 
tion, a muddy skin, a yellow conjunctiva ; of nervous disturbance — as 
restlessness, wakefulness, despondency, irritability, peevishness, or ex- 
hilaration, and high spirits, etc. ; or they may experience a more or less 
febrile condition, as shivering, rise of temperature, and sweating. In 
many cases any indications of the approaching tempest are wanting. 
The patient is awakened out of a sound sleep about 2 a. m., or be- 
tween 12 M. and 5 a. m., with a sense of uneasiness rapidly growing 
into acute pain in the ball of the great-toe, if a recent case. The part 
the seat of pain is red, hot, swollen, and so exquisitely sensitive that 
the lightest touch, the weight of the bedclothing, the jar of one walk- 
ing over the floor, can not be borne. The veins of the foot are swollen. 
Kow and then the muscles of the leg start with sudden spasms, and a 
hot pain pierces the joint. No position gives relief. If the foot be 
placed on the floor the veins swell still more, the joint becomes deep 
red, almost purple, and the pain becomes agonizing, so that the patient 
gladly foregoes any attempt to walk. As a rule, a feverish state de- 
velops ; some chilliness is first experienced, then the temperature rises, 
the pulse quickens, there are thirst and a coated tongue. The urine 
voided during the paroxysm is dense, deep red, acid, and deposits copi- 
ously the brick-dust sediment. After several hours of severe suffering, 
and in the early morning, the pain abates, the skin is covered with a 
warm prespiration, and a general sense of relief is experienced. If, 
now, the foot is kept elevated and at rest, and all excitement avoided, 
the relief continues through the day ; the joint is less red, less swollen, 
and less tender ; but when evening approaches sharp pains again fly 
through the joint, the swelling rises again, and another night of agony 
is passed. The same experience may be repeated for several days and 
nights longer — exacerbations at night, comparative ease by day. If 
no treatment of any kind is instituted, the case may continue in this 
way for a week, for ten days, even for two weeks, but the usual dura- 
tion under the present treatment is but four or five days. "When the 
joint and surrounding tissue are much swollen, the pain becomes less 



GOUT. 



933 



severe ; but toward the end of the paroxysm the swelling subsides, the 
redness also, and desquamation of the epidermis is apt to take place in 
fine scales, and sometimes in large flakes. The swelling veins collapse, 
but when the foot is first placed on the floor they quickly fill, and the 
whole member feels sore, and tingles, and is painful from a fine prick- 
ling. The ankle and foot are stiff and awkward for many days. The 
system is much depressed by an attack of acute gout, the body-weight 
is lessened, the lines deepen in the face. When the attack is over, the 
ravages committed by it are quickly repaired, and a feeling of well- 
being, often of exhilaration, takes the place of the hebetude of mind, 
and the bodily distress, or other disagreeable sensations which pre- 
ceded the outbreak. The patient may continue free from gouty parox- 
ysms for two or three years, but he is usually visited again in about a 
year. The same joint may be attacked as before, which is more fre- 
quently the left metatarso-phalangeal joint of the great-toe, but this 
seizure may be concerned with the right, or both. A similar inter- 
val may elapse before the next seizure, when the inflammation may be 
in the same joints as in the previous paroxysms, or may extend to 
the other articulations of the foot, and to the ankle. In the further 
progress of the case other joints are affected — those of the upper ex- 
tremity, the hip, the knee, etc. — and the attacks come nearer together, 
until ultimately they may be expected at any time. As the parox- 
ysms increase in number, they decline in severity, but grow longer 
in duration. The skin does not recover, but remains red and livid, 
while the veins become varicose. Meanwhile, the systemic condition 
tends to permanence, and the general as well as local symptoms 
persist. 

Chronic Gout. — The distinction between acute and chronic gout 
consists in the wider diffusion of the articular troubles, their less pro- 
nounced character, and the preponderance of the constitutional state, 
in the latter or chronic form of the malady. The affections of the 
digestive organs, which precede the paroxysms, and are present in less 
degree at all times, consist of acidity, flatulence, pain about the epi- 
gastrium and through the hepatic region, distress after eating, haemor- 
rhoids, constipation alternating with diarrhcea, a coated tongue, and 
fetid and heavy breath. Sometimes the paroxysms are preceded by 
various nervous symptoms — especially by feelings of depression, irri- 
tability, twitching of the muscles, cramps in the legs, palpitation, and 
occasionally intermittence of the heart-beat. The paroxysms occur at 
any time, but they develop slowly, and there are less pronounced local 
and general symptoms, and they do not have the critical character, 
nor produce the relief, of the acute seizures. The deposits about the 
joints increase with the duration of the case ; and the joints become 
hard, knobby, and are often much distorted. These deposits or tojphi 
(chalk-stones) form not only about the joints proper, but in the ten- 



934: 



DISORDERS OF NUTRITION. 



dons and bursa, producing deformity and seriously impairing the func- 
tions of the articulations. Among other places, these tophaceous de- 
posits form on the helix of the ear. 

Course, Duration, and Termination. — Gout is a very chronic disease, 
for, although there is an acute gout^ this form is merely an exacerba- 
tion of the chronic disease. The first paroxysms are separated by 
long intervals, but after some years the chronic gout is established. 
This continues with varying fortunes for several years. The compli- 
cations which increase the gravity of the disease are numerous. The 
chalk-stones seem at first to be important only as they deform joints 
and impair functions, but they are foreign bodies, excite inflammation 
and ulcerations which show no disposition to heal, but continue to 
discharge, and if numerous may wear out the strength and cause death 
by exhaustion. The changes in the kidneys ultimately become highly 
influential factors in the morbid complexus. These organs separate 
less and less excrementitious matter ; the urine is pale, of low specific 
gravity, and contains albumen. The changes in the kidneys may be 
the main causes of the cerebral symptoms which occur toward the end, 
and of the cerebral haemorrhage with which so many gouty subjects 
are carried off. During the course of chronic gout, various troubles 
arise in internal organs, and are styled gouty. " Gout in the stomach," 
" gout in the head," are popular phrases, which indicate the general 
belief that gout abandons the joints to attack internal organs. This 
notion was also represented in the technical phrase "retrocedent 
gout." That such a retrocession, or metastasis, does actually occur, is 
no longer maintained. Important changes of structure take place in 
internal organs, as a result of chronic gout, and hence, indirectly, gout 
may be responsible for various diseases. "Gouty kidney," as it is 
called, and the serious result of the change have been already re- 
ferred to. Atheromatous and calcareous degeneration of the vessels 
leads to attacks of angina pectoris (gout in the heart, in popular lan- 
guage) and to cerebral haemorrhage (gout in the head). The changes 
in the composition of the blood, which belong to gout, are fruitful 
causes of acute inflammations, as pneumonia, pleuritis, etc. The 
mode in which cases of gout may ultimately terminate is indica- 
ted in these observations on the changes wrought by the disease. 
When the lesions of chronic gout are established, we must take 
a hopeless view of the situation. When the disease is inherited, al- 
though it may not have proceeded far, the probability of afford- 
ing some permanent relief is less than in the acquired disease. 
When the first paroxysm has occurred, the prognosis will be great- 
ly affected by the disposition of the patient and his power of self- 
control. 

Diagnosis. — Errors of diagnosis are possible only in the case of 
chronic gout, and between this and arthritis deformans. The differ- 



GOUT. 



935 



entiation may, however, be readily made. Arthritis deformans occurs 
among the poor and ill-nourished — in women chiefly, and at or before 
middle life. There are no paroxysms ; it is gradual in its growth, and 
affects the two sides in a symmetrical manner, and is not accompanied 
by urate-of-soda deposits. 

Treatment.— The treatment of gout is concerned with the parox- 
ysm, with the chronic form of the disease, and with the intervals be- 
tween the paroxysms. There are two methods of treating the parox- 
ysms of gout — the expectant and the eliminant. By the expectant, 
the patient is put at rest, the joint is wrapped in cotton-wool, a laxative 
is administered, and the diet is reduced to slops. Under this method 
the duration of the attack is protracted, but the ultimate results are 
better than if more active treatment were pursued, provided the pa- 
tient make such change in his mode of life as may be necessary. The 
suffering is so great, however, that the patient is usually clamorous for 
relief, and hence more active measures are necessary. There are but 
two remedies which exert a really curative influence on gout — colchi- 
cum and salicylic acid. Colchicum has been used for many years, and 
has demonstrated its power to alleviate the pain and shorten the dura- 
tion of the acute attacks. The active principle, colchicine, is prefer- 
able to the crude drug. It may be given advantageously with quinine, 
morphine, and compound extract of colocynth. The wine and tincture 
may also be employed. In the various prescriptions for gout, besides 
colchicum there are usually an alkali, a potash-salt, and a purgative, 
colocynth. The object is to secure elimination of the urate of soda 
and prevent its deposition. Salicylates have recently been employed 
with great success to relieve the gouty attack. They may not be given 
when the stomach is very irritable, or in atonic gout, but, in the usual 
acute gout in a vigorous subject, the relief afforded is surely remark- 
able. If the stomach is very irritable, effervescing salines — the com- 
mon effervescing, or the Sedlitz-powders if there be constipation — are 
useful by promoting elimination by the various organs of excretion. 
If the pain is very severe, morphine, hypodermatically, will afford 
prompt relief, but remedies of this kind must be used sparingly be- 
cause of their effect in stopping elimination. Local treatment is of 
doubtful utility. Leeches applied in the neighborhood are of real 
service if there is much swelling, the patient robust, and the attack 
recent. Blisters in the neighborhood of the joint are always safe, are 
useful as regards the subsequent course of. the case, and afford much 
immediate relief. Besides these measures, it is necessary only to sup- 
port the foot at a considerable elevation, maintain rest, and cover the 
painful joint with some cotton. Excessive warmth and much cover- 
ing are hurtful. A man who has suffered an attack of gout should at 
once change his mode of living. As to drop from an abundant and 
rich diet to a poor and spare diet involves much risk, the change 



936 



DISORDERS OF NUTRITION. 



should be made gradually. The diet of a gouty subject should con- 
sist chiefly of vegetables and fruit ; he should take fresh meat once a 
day ; coffee and tea should be given up, and skimmed milk substituted; 
eggs are also injurious, and all dishes into which eggs enter ; pastry, 
cakes, hot bread, sweetmeats, spices, and condiments, are to be avoid- 
ed, while oysters, fish, soups, may be eaten. Next to careful regula- 
tion of the diet, exercise is most important. Walking, riding, rowing, 
but especially walking, should be carried out systematically, and, when 
inclement weather prevents exercise without, it should be done in-doors. 
If no other mode of exercise is possible, passive movements, massage, 
and faradization of the muscles, can be conducted in bed if need be. 
Cold bathing is objectionable. The patient should wear flannel, and mi- 
grate from a cold winter climate to a warm one if his means permit. 
Certain kinds of waters are serviceable : in this country, Saratoga, es- 
pecially the Vichy spring, the alkaline waters of Wisconsin, and of 
St. Catharine's, Canada, the Warm Springs of Virginia, and the Hot 
Springs of Arkansas ; abroad, Vichy, Carlsbad, Wiesbaden, Homburg, 
etc. Elimination may be maintained by drinking freely of ordinary 
drinking-water. Much of the efficacy of alkaline waters is due to the 
quantity of fluid swallowed. Excellent results are obtained from the 
use of the lithia salts in chronic gout. These preparations promote the 
excretion of uric acid, and apparently the solution of the deposited 
urate of soda. The interval between the attacks is lengthened, and 
the attacks are less violent and of shorter duration, when the citrate of 
lithia has been given for some time. In atonic gout a modified course 
must be pursued. With the potash and lithia salts must be combined 
quinine and iron ; the food must be nourishing without being abnor- 
mally stimulating, and massage and f aradism perform the part of active 
exercise. 

ARTHRITIS DEFORMANS. 

Definition. — By arthritis deformans is meant a chronic inflam- 
mation of the joints, without fever and without suppuration, pro- 
gressive, and causing nearly symmetrical enlargement and deformi- 
ty of various articulations. It is called rheumatoid arthritis by 
Garrod, and rheumatic arthritis and rheumatic gout by various 
authors. As the supposed rheumatic character of the disease is 
more than doubtful, the term employed by the German writers — 
arthritis deformans — is preferable, because no theory is coupled 
with it. 

Causes. — Arthritis deformans does not appear to be propagated by 
hereditary tendency. It is more especially a disease of women than 
of men, and is apparently associated with disorders of the menstrual 
function, particularly at the climacteric period. Cases do occur among 
men, and sometimes they are exceptionally severe. Poverty and bad 



ARTHRITIS DEFORMANS. 937 

hygiene, exposure and hard work, with inadequate food, prolonged 
lactation and frequent pregnancies, are among the most influential 
causes. Garrod holds that it may have its origin in the tubercu- 
lar diathesis. It is usually regarded as a disease of advanced life, 
but cases occur from the period of puberty on. Moral causes are very 
influential in its production — for the disease has repeatedly followed 
grief, anxiety, and moral depression. As various changes in the joints 
are produced by certain troubles of the spinal cord, a state of the 
nerve-centers is invoked to account for this disease. Joints that are 
injured, as the ball of the great-toe by a tight shoe, are the first to 
undergo the change. 

Pathological Anatomy. — At an early period there are seen only the 
changes of inflammation — hyperaemia of the synovial membrane and 
an increased amount of fluid in the joint. After absorption of fluid 
has occurred, the capsule of the joint is found to *be thickened, and 
the ligaments are elongated, thus permitting ready dislocation. The 
cartilages are absorbed, and the bones rubbing together are polished 
and hard, like ivory, a condition which is called "eburnation." The 
articular extremities become thickened and broader, and are flattened 
out, their margins projecting, and studded with irregularly rounded 
bony outgrowths. The fluid contents of the affected joints consist 
of a much altered synovial fluid, especially rich in mucin, and con- 
taining cholesterin and lecithin (Hoppe-Seyler *). In occasional cases 
the capsule of the joint is partly or wholly ossified. Not only the 
joints, but the adjacent tendons and their sheaths and the bursae, 
become ossified, and the muscles waste and undergo fatty degen- 
eration. 

Symptoms. — Slow enlargement of a joint that is exposed to injury, 
as the wrist in a laundress, the thimble-finger in a seamstress, or, after 
a more or less prolonged period of trouble and anxiety, the general 
health being reduced by nursing, the knee or some other joint becomes 
painful and swells. The first attempt may subside, and presently the 
same joint or another may undergo the same process, but a subsidence 
no longer takes place, and the joint remains swollen. In a short time 
other joints are attacked. In other cases the first symptom experi- 
enced is pain in the articulations, which subsequently become swollen. 
The joint is sensitive to atmospherical changes, and feels sore when 
flexed or extended. Acute pains extend along the nerves in the neigh- 
borhood. Thus, if the changes have begun in the hip, the pain is felt 
in the sciatic nerve. After the pain has continued for some time, the 
joints are observed to be enlarging. The fingers and toes, knees and 
wrists, are affected in the more youthful subjects, while, in the senile, 
the hips, spine, and shoulders are more especially visited. When the 

* Yirchow's "Archiv," Band It. s- 252. 



938 DISORDERS OF NUTRITION. 

deposits about the joints have attained a certain magnitude, their 
mobility is lessened. After a more or less prolonged rest the parts 
become rigid, and motion is difficult until the persistent use of the 
members limbers them again. The osseous deposits about the joints 
and tendons at length reach such a stage of development that the 
affected joints have a very limited range of movement. The thick- 
ened joints are not red, but pale, and, although painful, are not tender. 
The changes in the articulating surfaces and the relaxation of the 
tendons lead to subluxations. When the articular cartilages are re- 
moved, and the ends of the bones rub together, a grating is produced 
that is felt by the patient and through the soft parts. This crepitant 
sound may also be due to the movements of the tendons through 
their partially ossified sheaths, or by the collision of the osseous 
masses which form about the various articulations. The hands are 
peculiarly prone to take on this deformity. The heads of the meta- 
carpal bones and the phalanges are distorted by large nodules. " The 
metacarpo-phalangeal articulations of the fingers are flexed, the first 
phalangeal extended, causing the second phalanx to be thrown back- 
ward, and the second phalangeal joint is also flexed. The phalangeal 
joint of the thumb is usually extended or bent backward" (Garrod). 
When the larger joints of the lower extremities are affected, especially 
the hip, the gait has a characteristic halt and limj). The spread of the 
arthritis through the articulations is symmetrical, or nearly so.* The 
muscles of the limbs waste, the subcutaneous fat disappears, and hence 
the members have a wasted appearance, which recalls the myopathies 
of spinal origin. When the vertebrae are affected, anchylosis takes 
place, reducing the flexible spinal column to the rigidity of an iron 
bar. Various ill results follow. If the cervical vertebrae are anchy- 
losed, the patient's head is kept erect and rigid without power of bend- 
ing or turning ; if the dorsal and lumbar vertebrae are anchylosed, the 
body is twisted and immovable. In the worst cases, finally, all the 
joints are spoiled, are fixed in bony anchylosis, and motion is no longer 
possible. 

Course, Duration, and Termination.— Arthritis deformans is one of 
the most chronic of diseases, continuing on its course for ten, twenty, 
even thirty years, or longer. It is a progressive disease, and does not 
cease or get well spontaneously, yet it sometimes remains stationary 
for months and years at a time. Although of itself not affecting the 
constitution in a marked way, and sometimes not at all impairing the 
general health, in other cases life is rendered intolerable and the 
strength is exhausted by suffering and loss of sleep. Most obstinate 
sciatica may attend on the disease in the hip, and neuralgia, contrac- 
tures, paralyses, etc., may be caused by the osseous deposits along the 

* Hutchison, " Transactions of the Pathological Society," vol. xxiii, p. 194. 



DIABETES. 



939 



spine. Otherwise the disease continues through life, not apparently- 
abridging it. 

Treatment. — The only remedies which have appeared to do any 
good are iodine and galvanism. The compound solution is an eligible 
form, which we may give in the dose of five minims, three times a day. 
Iodine-ointment may be carefully rubbed into the affected joints. 
The oleate of mercury and morphine may also be painted over (not 
rubbed in) the joint, and along the course of painful nerves. Galvanic 
currents should be transmitted through the cervical sympathetic, and be 
applied also to the affected parts, the principal nerve-trunks being in- 
cluded in the circuit. As many as forty to sixty cups should be used, 
and large, well-moistened sponge electrodes should be applied. Warm 
baths, massage, passive motion, and faradization of the muscles, are 
among the very useful expedients to be employed in these cases. Un- 
doubtedly good results have been obtained from the use of arsenic, if 
given early in the disease. If anaemia exist, as is so often the case, 
iron is necessary. If the nutrition is low, cod-liver oil and the hypo- 
phosphites may be given with advantage. 

DIABETES MELLITUS. 

Definition. — Diabetes is a chronic disease characterized by the 
constant presence of grape-sugar in the urine, by an increased urinary 
discharge, and by progressive wasting of the body. The occasional 
and temporary presence of sugar in the urine does not constitute dia- 
betes mellitus^ although it may precede the fully developed disease. 
Diabetes insipidus is a malady in which the urinary water is largely 
increased in amount. 

Causes. — Climate exerts a certain influence in the causation of diabe- 
tes, but the influence is capricious and there are no obvious reasons for 
the greater prevalence of this disease in one locality than in another. 
Race seems, in respect to one people at least, to be concerned — the 
Jews, who are apparently more frequently the victims of diabetes than 
the Christians. It is distinctly hereditary, and, although this fact has 
not been properly appreciated heretofore, the examples of hereditary 
transmission are becoming so numerous that this will hereafter occupy 
a high position in the etiology of the disease (Senator). Diabetes is 
more common in males — three to one, according to Brunton,* who bases 
his statement on the statistics of eight German and French authors. 
But this proportion does not hold good for children, with whom fe- 
males are more given to the disease (Dur and -Fardel, Senator), and this 
is the experience of the author. Diabetes occurs at all ages, but is 
most frequent in middle life — from thirty to forty for males, and 

* Reynolds's " System of Medicine," article " Diabetes." 



940 



DISORDERS OF NUTRITION. 



from twenty to thirty for females. There are two types of subjects 
addicted to the disease, the obese and the thin, and they represent two 
kinds of causes. The obese are addicted to the pleasures of the table, 
suffer from a certain kind of indigestion, and are given to sedentary 
habits. In the thin and nervous subject the disease comes on after 
some excitement, chagrin, business failure, or other cause of cerebral 
disturbance. Among the exciting causes must be placed mechanical 
shock, concussion of the whole body, or of the brain and spinal cord, 
blows upon the hepatic and renal regions, etc. Mental shocks, pro- 
found moral impressions, especially anxiety and chagrin, are, in the 
author's experience, very common causes in the class of subjects men- 
tioned above ; but, in the obese class, errors of diet, the consumption of 
a large proportion of farinaceous food and of malt-liquors are chiefly 
responsible. The occurrence of acid indigestion and the probable for- 
mation of lactic acid in the intestinal canal (the duodenum) are ele- 
ments to be considered in this connection. To these exciting causes 
must be added exposure to cold and wet while the body is heated, sex- 
ual excesses, extreme fatigue, etc. 

Pathological Anatomy. — There are two groups of morbid altera- 
tions : those which stand in an apparently causative relation to the 
disease ; those induced by it. In the intestinal canal the changes con- 
sist in a proliferation of the epithelial layer of the mucosa throughout 
the whole tract, in hypergemia and thickening of the mucous membrane, 
and also sometimes of the muscular layer. The muscular tissue of the 
heart is relaxed and fatty, and the vessels, especially the median and 
small -sized vessels, are atheromatous, the atheroma being more decided 
in the cerebral vessels at the base than elsewhere in the body. The 
blood is altered by a great increase in the amount of fat in the serum, 
which may even have a milky appearance from this cause. Atrophy, 
cystic degeneration, and, according to some, hypertrophy of the pan- 
creas, have been observed, but atrophy occurs in one half of the cases 
— a fact of great pathological importance. More significant changes 
occur in the liver, but these are by no means constant, for the liver has 
sometimes appeared to be quite normal. In twenty-seven cases exam- 
ined by Dickinson the liver was healthy in six. In Seegen's cases 
at the Vienna Hospital, thirty in number, fifteen presented obvious 
changes in the liver. In some cases which have been reported, the 
liver was enormously enlarged. The most constant changes consist in 
an active hyperaemia, generally diffused, the acini appearing as well- 
defined rose-colored spots surrounded by distended capillaries ; in en- 
largement of the hepatic cells with rounding of their contour, and 
occasionally in hypertrophic enlargement of the connective tissue of 
the organ. The kidneys are in an obvious pathological condition in 
more than one half of the cases — usually enlarged and decidedly hy- 
pergemic, without being otherwise altered. More or less fatty change 



DIABETES. 



941 



ensues in some instances, the infiltration of fat occurring in the corti- 
cal portion chiefly, giving to it a pale-yellowish appearance, and in- 
creasing its thickness. This fatty infiltration is no doubt due to the 
persistent hypersemia. Various morbid changes have been discovered 
in the brain and spinal cord, but they are by no means uniform in po- 
sition or character. Hyperemia, dilatation of the perivascular lymph- 
spaces, remains of old extravasations, pigmentations, fatty degenera- 
tion of cells, tumors, etc., have been found in various parts of the brain, 
cord, medulla, pons, etc. Important lesions, also, have been made out 
in the semi-lunar ganglion, solar plexus, and splanchnic nerves ; they 
have been seen much enlarged, thickened, and of almost cartilaginous 
hardness. These changes appear to be the cause of the extraordinary 
wasting of the pancreas which so often takes place. The lungs are fre- 
quently far advanced in phthisis. In only two of twenty-seven diabetics 
under the observation of Dr. Dickinson were the lungs free from the 
various alterations of phthisis at some stage of its development. The 
body at death is extremely emaciated. Remains of ulcers, abscesses, 
and gangrene sloughs are to be seen in the skin of various parts. The 
muscular tissue is dry, anaemic, relaxed, and its color pale, but it is 
sometimes of a reddish-brown. 

Symptoms. — There are two distinct types of subjects who are 
affected by diabetes : the obese and phlegmatic ; the thin and nervous. 
The onset and the behavior of these two varieties are very different. 
A recognition of the peculiarities of each is necessary to a proper com- 
prehension of the malady. In the obese subjects the onset of the 
disease is gradual ; they experience, for a long time previous to the 
beginning of the malady, disorders of digestion ; they suffer from acid- 
ity, pyrosis, and a sense of epigastric weight and uneasiness. Not- 
withstanding the obvious derangement of the digestion, they have a 
keen, almost an insatiable appetite, and a strong thirst, and they con- 
stantly increase in weight up to a certain point. They pass, at this 
period, an excessive amount of water, and the urine occasionally con- 
tains sugar, but not constantly by any means. They are troubled 
with boils or carbuncles, and often have hard, inflammatory swellings, 
which slowly suppurate, and discharge with a considerable slough, 
leaving an indolent ulcer behind which shows but little tendency to 
heal. In the thin, nervous type, the opposite conditions obtain. These 
subjects are nervous, suffer from attacks of neuralgia, and are rather 
hypochondriacal. With them, digestion is never active ; they are 
rather constipated, and the functions of the gastro-intestinal canal are 
as a rule performed with a certain feebleness, without there being any 
pronounced derangement. The disease usually comes on abruptly. 
There may have been headache, neuralgia, or mental despondency, but 
these symptoms have no necessary connection with diabetes. After 
some business troubles, anxiety, grief, or other moral cause, it is ob- 



942 



DISORDERS OF NUTRITION. 



(served that there is an unusual urinary discharge, that the strength is 
exhausted by the least effort, and that a sense of fatigue is constant. 
When the disease has really begun, there are present constant thirst, 
dryness of the mouth and tongue, an unusual appetite, and frequent 
discharge of urine, in large amount at a time. In other cases the 
vision is impaired, and the diagnosis is made by the oculist, to whom 
the patient has repaired for advice about his eyes. The thirst is ex- 
cessive, and the amount of water and of other fluids drunk is enor- 
mous ; the appetite becomes voracious, insatiable, and the individual, 
who previously had been rather indifferent to food, now gloats over 
the viands placed before him, and thinks only of satisfying his ap- 
petite. A frequent desire to micturate comes on with the thirst, the 
patient is disturbed repeatedly at night, and in the morning the vessel 
contains a much larger quantity than usual. The aggregate amount 
passed in twenty-four hours may reach 80 to 100 ounces or more ; 
it is acid in reaction, and has a specific gravity of 1020 to 1040, even 
1050. The bowels are confined, the faeces hard, and voided with diffi- 
culty. The saliva is acid. The tongue is pasty, deeply fissured, some- 
times blackish, dry, and hard. The gums may be soft and spongy, 
the teeth loose and apparently elongated, because of the retraction of 
the gums. The breath has a peculiar mawkish, disagreeable odor, 
likened to that of new hay or of new apples. The skin becomes dry 
and rough and is attacked by herpes or eczema, and, when emaciation 
proceeds to a considerable extent, is wrinkled and inelastic. The eye- 
lids may be swollen. In one of the author's cases, ptosis appeared 
with the first symptoms. Headache, vertigo, double vision, neuralgia, 
wakefulness, deep dejection of mind, abnormal sensations in the skin, 
formication, are nervous symptoms, especially apt to occur in the thin, 
nervous type of subjects. The sexual appetite early declines, and is 
soon wholly absent, the erections ceasing permanently. Itching at the 
orifice of the urethra is an early symptom in both sexes, but especially 
in women. The itching may extend from the meatus to the vulva 
generally, and produce intolerable torment. Whenever this symptom 
occurs in obese women, the urine should always be examined. The 
prepuce and the vulva, also, are excoriated by the passage of the 
saccharine urine so frequently. Such are the symptoms of the dis- 
ease in its process of development. It is necessary now to indicate 
with somewhat more detail the chief features of the malady at its 
maximum. 

The remarkable increase in the urinary discharge is the most strik- 
ing phenomenon. We have already mentioned eighty and one hun- 
dred ounces as a not unusual quantity, but these figures have been 
largely exceeded in some cases, e. g., Bence Jones, who reports a case 
passing seven gallons. On the other hand, the urine may not be in- 
creased above the normal, or may fall below it. Toward the end 



DIABETES. 



943 



there may be a notable decline in the quantity of urine, and this fatal 
symptom may be entirely misconceived. The amount of urine dis- 
charged stands in a nearly constant ratio to the amount of water drunk. 
The apparent exceptions to this are cases of patients unable to swallow 
much fluid, the surplus over that taken into the body being formed by 
the oxidation of the hydrogen, or supplied from the water stored up in 
the tissues. The urine of diabetes is clear, of a faint greenish tinge, 
and is free from sediment. If it stand for some time in a warm place, 
it is covered with the Torula cerevisim, or yeast-fungus. The urine is 
acid in reaction. The specific gravity, as already stated, ranges from 
1020 to 1050, but it may contain sugar, and yet fall below normal. 
The variety of sugar present in the urine is grape-sugar and not cane- 
sugar, the variety in domestic use. The former differs from the latter 
in the readiness with which it ferments, in turning the plane of polar- 
ized light to the right, and in its source, the grape-sugar of commerce 
being obtained from starch by the action of sulphuric acid. Grape- 
sugar is also less sweet than cane-sugar, and is harder in texture. The 
actual amount of grape-sugar present in urine ranges from a mere trace 
to ten, even fourteen per cent. Dickinson reports an extraordinary 
case of a man who excreted in twenty-four hours fifty ounces of sugar. 
The quantity of sugar stands in a certain ratio to the amount of urine 
— the larger the flow of urine the greater the quantity of sugar voided ; 
and to the character of the food, for the more sugar and starch in the 
food the more sugar in the urine. The high specific gravity of the 
urine is not wholly due to the presence of sugar, but is also influenced 
by the quantity of urea, which may rise to a proportion two or three 
times greater than the normal. This increase of urea is due to the 
largely increased consumption of nitrogenous diet, and to the greater 
metamorphosis of the nitrogenous tissues. As the formation of urea 
is one of the hepatic functions, the increased production of this sub- 
stance may be due to the heightened functional activity of the liver. 
Albumen is present in a proportion of cases not definitely settled. It 
may be due to the increased blood-pressure. Irritation of a spot on 
the floor of the fourth ventricle causes albumen to appear in the urine, 
as irritation of another spot below causes an excretion of sugar. Ino- 
site, or muscle-sugar, has taken the place of grape-sugar in some rare 
cases. Acetone has also appeared in the urine in a few cases. Vari- 
ous affections of the special senses occur during the course of diabetes. 
Ptosis has been mentioned. Amblyopia, paralyses of accommodation, 
and amaurosis, also occur. The most striking phenomenon connected 
with vision is the occurrence of cataract, which is encountered in the 
proportion of one in twelve to one in forty-five cases. The cataract 
is of the soft variety, and both eyes are usually attacked, that in the 
right eye developing more rapidly. The formation of cataract is sim- 
ply a failure of the nutrition of the lens in consequence of the state 



9M 



DISOEDERS OF NUTRITION. 



of the blood. Owing to the same cause, boils and carbuncles appear 
among the prodromic symptoms and also at the maximum of the dis- 
ease. Carbuncles may indeed be the cause of death. Gangrene of 
the skin, and gangrene of a toe, foot, or leg, may also occur. The 
great loss of material continually going on must necessarily cause 
wasting, emaciation, and a sense of fatigue. A rapid accumulation of 
flesh — of adipose — takes place in the obese subjects of diabetes when 
the disease begins, for then the retrograde changes through the chan- 
nels of excretion are not so active as the source of supply. But pres- 
ently the waste exceeds the supply, and then a rapid loss of weight is 
observed. Patients going through this process present a very char- 
acteristic appearance : they have an old look, and may be much 
wrinkled ; the skin is rough, cracking at the ends of the fingers, and 
the countenance wears an anxious expression. The lips are pallid, the 
mouth dry, the tongue dry and hard, and constant smacking of the 
lips and sucking of the tongue, in the vain eifort to moisten the parts, 
are characteristic of diabetics. As the nutritive functions are so de- 
pressed, it is not surprising that the temperature of the body should 
remain below the normal. It has been found as low as 93-2° by Dick- 
inson. Foster * has pointed out the very curious fact that the tem- 
perature of the fluids drunk exercises an influence on the temperature 
of the diabetic patient. His figures show that, when all fluids drunk 
were warm, the temperature of the axilla was one degree higher than 
when the fluids were cold. 

Course, Duration, and Termination. — In the obese type the prodromes 
may continue over several months, even years. There may be occa- 
sional glycosuria, of variable duration, occur several times, before the 
persistent presence of sugar constitutes the case one of diabetes. On 
the other hand, in the nervous type, the preliminary symptoms are of 
brief duration. So long as the appetite and digestion are equal to the 
supply of all the material excreted, the patient holds his own. When, 
however, the loss is in excess, the decline is rapid. The cases vary 
greatly in the rate of progress. Those diabetics, in whom the proper 
regulation of the diet causes a disappearance of all the symptoms, ap- 
parently recover, and the duration may therefore be much prolonged, 
but they ultimately succumb, because they at length reach a period 
when they can no longer prevent the formation of sugar. Those cases 
proceed rapidly in whom the changes of diet make but little differ- 
ence in the formation and excretion of sugar. The average duration 
is about two to three years. Under proper management favorable 
cases, not curable, may continue for many years, the patient mean- 
while enjoying good health. Age has much to do with the rate of 
decline. The disease makes very rapid progress in children. The 



* " Clinical Medicine," by B. Foster, M. D., Philadelphia edition, p. 264. 



DIABETES. 



945 



most acute cases terminate in a few weeks. The prognosis is most un- 
favorable as regards cure, and gloomy in respect to retardation. The 
reports of recovery are discredited by those of greatest experience. 
While cures may not be hoped for, in a considerable proportion of 
cases decided amelioration may be accomplished and a retardation of 
great length effected in a small number. Much depends on the influ- 
ence of the changed diet over the excretion of sugar ; for, if, on a nitro- 
genous diet, the sugar disappears from the urine, the case wears a 
decidedly more hopeful aspect than if the formation of sugar contin- 
ues despite the change. In the further progress of the case, the con- 
dition of the patient will depend largely on the behavior of the diges- 
tive organs as confined to an animal diet. If he can not persist in this 
diet, and his digestive organs are upset by the nitrogenous food, a 
prompt development of the worst symptoms will ensue. The mode of 
dying is various. Death by exhaustion is not common. In some 
cases, apparently doing well, the most serious symptoms, known as dia-. 
hetic coma, suddenly appear. Great restlessness, praecordial uneasiness, 
and pain are quickly manifest ; somnolence, with general agitation, 
loud cries and groans, and then a deepening coma, come on, during 
which the pulse growls weaker, the respirations more and more shal- 
low, the temperature lower and lower, and soon the patient expires in 
a condition of profound insensibility. These symptoms of such for- 
midable character, and arising suddenly, wear an aspect of poisoning, 
very like that caused by acetone in animals. As this substance may 
be produced in the blood by the decomposition of the diacetate of 
ethyl-~a product of the reactions of grape-sugar — it is assumed that 
diabetic coma is an aeetoncemia. The most frequent cause of death 
is phthisis. This may develop very slowly and escape detection until 
far advanced, or it may proceed very rapidly and with pronounced 
symptoms from the beginning. Gangrene of the lung rarely occurs, 
and it presents the remarkable peculiarity that the sputa are without 
odor. 

Diagnosis. — Diabetes exists only when sugar is permanently pres 
ent in the urine. In diabetes insipidus there is a large flow of water, 
but no sugar ; in glycosuria of the temporary kind sugar is only occa- 
sionally present. It is not the quantity, but the persistence of the sugar, 
which constitutes diabetes. As Senator well expresses it, "a saccha- 
rinity of over two per cent, certainly occurs in diabetes, but a lower 
saccharinity does not exclude diabetes." The urine of diabetes has 
certain physical peculiarities by which it may be recognized, but not 
with the certainty of chemical reactions. It is free from sediment, 
has the appearance of water of a very pale-greenish tint ; has an acid 
reaction, and a specific gravity of 1025 to 1050 or higher. The im- 
portance of a high specific gravity depends on the fact that the quan- 
tity of urine is also large. The presence of sugar is the important 
62 



946 



DISORDERS OF NUTRITION. 



point, and this must be determined by the applications of chemical 
tests : 

Trommer^s test is the most generally applicable. A few drops of a 
dilute solution of sulphate of copper are added to some urine in a test- 
tube, or sufficient to give to the urine a blue color, faint but yet dis- 
tinct. Then the same quantity of liquor potassm as there is urine is 
added. If sugar be present, the precipitate at first formed is redis- 
solved, and the mixture assumes a deep-blue color. If, now, heat be 
applied, a yellow or orange-red precipitate of oxide of copper is thrown 
down. If the heat be applied to the upper part of the liquid, the vivid 
yellow color of the oxide of copper appears bright and distinct by com- 
parison. 

Fehling''s test solution must be kept prepared, and, as it rapidly 
spoils by keeping, frequent renewal of the solution is necessary. This 
test consists of a sulphate-of-copper solution, mixed with a solution 
of tartrate of soda and potassa (Rochelle salt) and caustic soda. Some 
of this test is added to the urine in a test-tube and boiled, the reaction 
being the same as in Trommer's. 

Fermentation Test. — Some brewer's yeast is added to the urine in 
a bottle and kept at a proper temperature (60° to 80° Fahr.). The 
bottle must be well corked and have a bent tube connected with it, so 
that the carbonic acid can be collected for examination. 

3foore's test consists in simply boiling together equal parts of urine 
and liquor potassce. The sugar is decomposed, and one of its prod- 
ucts is melassic acid, which may be recognized by its odor, and 
which, with glucic acid, another product, converts the mixture into 
a brown, almost a black color. The change of color is rendered all 
the more evident by confining the heat to the upper portion of the 
mixture. 

Treatment. — The most important points in the management of this 
disease are diet and exercise. Medicines are secondary. As the pres- 
ence of sugar in the blood is the great cause of mischief, our efforts 
must be directed to prevent its formation. This can be accomplished 
only by systematic disuse of all articles of food convertible into sugar- 
Bread, potatoes, beans, peas, rice, carrots, turnips, parsnips, etc., and all 
articles containing flour, sugar, or starchy must be excluded. Greens, 
cabbage free of the stock and stems, lettuce, tomatoes, and spinach, 
may be substituted. A bread made of powdered almonds and gluten 
bread may also be substituted for ordinary bread. Milk may be allowed, 
especially buttermilk. Donkin reports cures made by confining the 
patient to an exclusive diet of skimmed milk — six to eight pints daily. 
Brunton objects to the skimmed milk because some die of inanition, 
although he says others do recover. All kinds of flesh, fresh or salt, 
fish, including oysters, eggs, gelatine, fats, almonds and nuts, except 
chestnuts, are allowed ad lihitu7n, unless the too great consumption 



DIABETES. 



947 



of animal food induce tlie excessive excretion of urea and uric acid. 
Koumiss may be taken — also light acid wines and a little spirit with 
meals. Water may be taken to satisfy thirst, but a large quantity of 
fluid at meals must prove detrimental to digestion and should not be 
indulged in. Walking exercise is of the highest moment. There is 
a strong sense of fatigue proper to the disease, and the muscles are 
actually unequal to much effort. Surprising results may be accom- 
plished by active walking exercise, especially in the case of the obese 
diabetic. The strength is improved, and the formation and excretion 
of sugar are diminished. The functions of the skin should be main- 
tained by warm clothing. It is probable that pilocarpine will prove 
beneficial by increasing the secretion of the sweat and saliva. Of the 
medicinal remedies but few have proved beneficial. Opium, and espe- 
cially the alkaloid codeine,* exercises a great infiuence over the excre- 
tion of sugar, but unfortunately the effect is not maintained. Large 
doses are well borne and are required. Next to opium is arsenic, 
which, especially in the form of the bromide of arsenic, has proved 
highly useful. The alkalies are also useful, especially the phosphate of 
sodium, which the author has found in some cases, those of full habit 
especially, to exercise an apparently curative effect. The weak alka- 
line waters of Wisconsin (Bethesda), drunk in large quantities, seem 
to have a very beneficial influence. The Carlsbad water of Germany 
and Yichy of France have had a reputation for generations in the 
treatment of diabetes. Saratoga Vichy, and our native lithia waters, 
may be substituted for the foreign waters. The bromides have proved 
useful in some cases, and the best results have been obtained from the 
use of bromide of ammonium. The carbolate of iodine (carbolic acid 
3 j, tincture of iodine 3 ij, given in the dose of one or two drops well 
diluted three times a day) has seemed to have excellent effects in 
some cases, and therefore deserves more extended trial. Lactic acid 
has proved very useful in many cases, and in the author's hands, in 
the form of lactophosphate of lime, has seemed to benefit the thin, 
nervous type of diabetics remarkably. In this class of cases the lacto- 
phosphate of lime and cod-liver oil have been even more advantageous; 
Lactic acid often produces rheumatism, which is an objection to its use, 
and may require its suspension. Foster holds that the good effects of 
the skimmed-milk, whey, and buttermilk cures are due to the forma- 
tion of lactic acid from the lactin. Other drugs employed on theo- 
retical considerations are ethereal solution of peroxide of hydrogen and 
valerian. Any good effects derived from the former are attributed by 
Foster to the ether. Valerian slightly influences the excretion of sugar, 
but has a remarkable effect on the urea, the excretion of which lessens 
considerably under its use. To these drugs must yet be added the 

* Pavy especially eulogizes the good elFects of codeine. 



948 



DISORDERS OF NUTRITION. 



fluid extract of ergot. This drug has not been of any real utility in 
diabetes, but has apparently cured cases of diabetes insipidus. 

DIABETES INSIPIDUS. 

Definition. — Diabetes i?isipidus is a disease having for its chief 
clinical feature the passage of a very large, often an enormous, quantity 
of pale, watery urine, free from albumen and from sugar. It is also 
known as polyuria^ polydipsia, etc. 

Causes. — Occasional examples of hereditary transmission have been 
reported. The disease occurs at all ages, but is most frequent from 
twenty to forty-five. Men are more subject to the disease than women. 
Among the exciting causes are injuries and diseases of the brain, in- 
cluding concussion, tumors, exostosis, psychical impressions, etc. ; ex- 
j)Osure to draughts of cold air, the body perspiring freely ; drinking 
freely of cold drinks ; sudden variations of temperature ; fatigue, con- 
valescence from fevers, etc. According to the author's experience, the 
most usual cause of the disease is syphiloma of the brain. 

Pathological Anatomy. — But infrequent opportunities have occurred 
for a study of the changes proper to this disease. Two classes of le- 
sions have, however, been ascertained : of the brain and sympathetic 
ganglia ; of the kidneys. In the brain, changes have been found in the 
fourth ventricle — inflammatory and degenerative — tumors in this re- 
gion and in the cerebellum, tubercles, syphilitic tumors, etc. Degen- 
eration of the solar plexus has been observed by Dickinson. The 
changes observed in the kidneys are various — sometimes the organs 
are enlarged and hypersemic ; sometimes the only change is dilatation 
of the tubules. Other lesions, which must be regarded as accidental, 
have been noted, as cancer of the liver, tumor of the uterus, and disease 
of the mesenteric glands. 

Symptoms. — It is rare for the disease to begin in perfect health with- 
out any warning. The rule is, that the nervous disturbances associated 
with the various lesions of the brain occur. In the author's observa- 
tion there were the usual symptoms of cerebral syphilis preceding the 
outbreak of polyuria. The large flow of urine is the growth of several 
weeks. When the maximum is attained the flow is prodigious, but it is 
by no means the same in all cases, for it varies from one to five gallons 
daily. The single discharges are large, because the urine is not stim- 
ulating, and can, therefore, be longer tolerated by the bladder. The 
specific gravity of the urine is as low as 1002, and does not go above 
lOOT. The urine is pale, usually clear, faintly acid in reaction, and 
readily decomposes. The solid constituents are somewhat increased. 
The excretion of urea is slightly greater than that of a healthy indi- 
vidual consuming the same amount of animal food, and is simply 



DIABETES INSIPIDUS. 



949 



due to the increased waste of the nitrogenous elements produced 
by the passage of so much water through the tissues. Uric acid 
is diminished, as might be expected, because of the increased for- 
mation of urea. The sulphates, phosphates, and chlorides, are also 
increased. There is no sugar present. The reported cases of dia- 
betes insipidus with albuminous urine were, doubtless, examples of 
fibroid kidney. 

AThen there ensues such a strong outflow through the kidneys, the 
results of the loss of so much fluid and solid material are the same 
as those of similar fluid discharges. There occur excessive thirst, a 
dry mouth, dry skin, and constipation. The increased excretion of urea 
explains the diminution of body-weight which takes place in this dis- 
ease, notwithstanding the appetite and digestion remain at the normal. 
Sometimes a decided lowering of temperature is observed, but this may 
be due to the ingestion of a large quantity of cold drinks. Instead of 
dryness of the mouth, there may be ptyalism. The skin, although usu- 
ally dry, as stated, may be normal, and there may be profuse perspi- 
rations. 

Course, Duration, and Termination. — The onset of the disease may 
be preceded by the symptoms of cerebral disturbance, due to the ex- 
isting lesions of the brain and sympathetic ganglia. The increase in 
the flow of urine and the consequent thirst may develop slowly, and 
be observed only when they are very pronounced. In still other cases, 
during convalescence from some acute malady, or after some vio- 
lent mental or moral shock, or some severe blow on or concussion of 
the brain, the disease begins abruptly. In most cases the disease is 
rather an inconvenience, owing to the frequent calls to micturate and 
the incessant thirst, than a dangerous malady. Death has resulted 
in as short a time as four months, but here the fatal result was due 
rather to associated lesions than to diabetes insipidus. Death may 
result from the disease, the continual loss of material leading to fatal 
exhaustion, but it is usually due to some intercurrent disease or cere- 
bral lesion. Although death is rarely due to the disease, the prog- 
nosis is not favorable as to cure, unless caused by syphilitic disease 
of the brain. 

Diagnosis. — Those temporary states in which a large quantity of 
urine is voided for a few days are all separated from diabetes insipi- 
dus by the lack of permanence. From diabetes mellitus it is differ- 
entiated by the specific gravity of the urine and by the presence of 
sugar. Diabetes insipidus is most apt to be confounded with fibroid 
kidney, for in the latter disease a quantity of pale, watery urine is 
passed, but it contains more or less albumen and hyaline and waxy 
casts, which are not present in the former. 

Treatment. — Several remedies have been of real service ; many 
others of no value. The iodides and mercury have quickly cured cases 



950 



DISORDERS OF NUTRITION. 



of syphilitic origin. Jaborandi has been successful in Laycock's 
hands, ergotin in those of Ringer and Da Costa. Valerian has been 
beneficial but not curative (Trousseau). Galvanism has certainly been 
of signal service in several cases, applied by one electrode to the neck 
below the occiput and the other to the hypochondriac regions in turn. 
From the point of view of the experience thus far gained, the follow- 
ing plan seems most promising : A course of iodide of potassium 
should be at first administered. The disease not yielding, galvanism 
should be used, and pilocarpine and ergotin should be tried succes- 
. sively if the first fails. Warm clothing should be worn, and a warm 
winter climate should be selected if practicable. 

ALCOHOLISM. 

Definition. — By the term alcoholism is meant the physical and men- 
tal changes induced by alcohol. The effects of a large quantity taken 
in a short time are known as acute alcoholism, and the term chronic 
alcoholism is applied to that state which is the product of the long- 
continued action of considerable quantities of the poison. Mania a 
potu is a delirium caused by the action of alcohol in large quantity in 
certain susceptible subjects : it is an acute alcoholic delirium. De- 
lirium tremens is a delirium with trembling, occurring in the course of 
chronic alcoholism, and is often induced by bodily conditions, as stom- 
ach derangement, which prevent the introduction of the accustomed 
stimulant. Usually, however, these terms are applied indiscriminately 
to both kinds of cases. 

Pathological Anatomy. — Acute Alcoholism. — The mucous mem- 
brane of the stomach is more or less red — often vividly so— from hy- 
persemia. The redness is not usually universal in the stomach, but in 
patches, the mucous membrane about the cardia being chiefly affected. 
There are, also, cloudy swelling and more or less detachment of the 
epithelium. Here and there are occasionally ecchymoses, and still 
more rarely ulcerations, which form in the lower part of the oesopha- 
gus and in the stomach. A more or less intense hypersemia, also, is 
evident in the mucous membrane of the trachea and bronchi. The 
lungs present the changes due to hypostasis, and less frequently of 
hepatization. Similar conditions are found in the brain. The mem- 
branes are more or less deeply injected, the puncta vasculosa more 
numerous than in the normal, and an oedematous state of the pia, of 
the perivascular lymph-spaces, and of the brain-substance itself, ex- 
ists. It is the condition, indeed, known to morbid anatomists as a 
" wet brain." 

Chronic Alcoholism. — There are but few organs and tissues not 
in some way changed in this condition of the system. The mucous 
membrane of the intestinal tract presents the usual evidences of chronic 



ALCOHOLISM. 



951 



catarrh. The connective tissue, especially around the tubular glands, 
undergoes hyperplasia, and, in contracting, subsequently encroaches 
on the caliber of these glands, which in consequence atrophy and 
degenerate. The mucous membrane is at first thickened, in conse- 
quence of the overgrowth of connective tissue, but the subsequent con- 
traction leads to atrophic changes, to shrinking. Extravasations of 
blood now and then occur, and, in the transformations which ensue, ap- 
pear finally as patches of pigment, rather thickly disseminated through- 
out the organ. Very frequently superficial ulcers — erosions of the fol- 
licles — take place. The sub-mucous connective tissue always under- 
goes hypertrophy. The cascum next to the stomach is the principal 
seat of these changes. But more important even are the changes taking 
place in the liver. This organ may be found enlarged, with its con- 
nective tissue in a state of active hyperplasia, or shrunken, nodulated, 
and hard, in the condition of sclerosis, or it may be more or less ad- 
vanced in fatty degeneration. These changes have been already de- 
scribed under their appropriate heads, and need, therefore, only to be 
mentioned here. Hyperplasia of the connective tissue of the kidneys 
and subsequent contraction also take place, forming the condition of 
chronic interstitial nephritis ; but this is not so frequent a change as 
the corresponding disease of the liver. The constant presence of 
alcohol in the blood alters its constitution in that it contains an excess 
of fatty matters, the minute vessels undergo atrophic changes also, 
and the functions of the sympathetic are depressed, so that local con- 
gestions are apt to ensue, as in the lungs. The walls of the veins some- 
times undergo great thickening, encroaching on the lumen of the ves- 
sels. The muscular tissue of the heart may undergo fatty degenera- 
tion,* and in the circulatory system there ensue, earlier and more ad- 
vanced, the senile changes of later years. 'Not less important are alter- 
ations in the structure of nervous tissue. The neuroglia of the brain 
undergoes hyperplasia, the ganglion-cells atrophy, the perivascular 
lymph-spaces are dilated, the vessels are atheromatous. The final re- 
sult is, that the brain-substance is firmer, shrunken, and the vacant 
spaces are filled with fluid. These changes are not equally advanced 
in all cases, nor do they always exist together, but in old subjects of 
chronic alcoholism they will be found in various degrees and stages of 
development. The membranes are also affected in various ways and 
to different degrees — opacities, thickening, exudations, etc., being by 
no means uncommon. Pachymeningitis, with haematoma, is now un- 
derstood to have its origin in chronic alcoholism. This condition may, 
indeed, be induced experimentally in animals — in dogs — ^by feeding 
them a long time alcohol with their food.f Similar changes occur in 

* Dr. A. Baer, " Der Alcoholismus," etc., Berlin, 1S18, p. 67. 

f Kreminansky, "Ueberdie Pachymen, int. hem. bei Menschen und Hunden," Band 
xlii, pp. 129, 321, Virchow's " Archiv." 



952 



DISORDERS OF NUTRITION. 



the neuroglia, in the vessels, and in the ganglion -cells of the spi- 
nal cord. 

Symptoms. — Acute Alcoholism. — The condition of alcoholic in- 
toxication is too familiar to require description here. The symptoms 
of profound intoxication, short of lethal, however, are important, if for 
no other reason, for the intricate diagnostic points involved. When 
a large quantity of some alcoholic fluid is taken, the stages of excite- 
ment and of rambling, with incoherent muttering, are soon passed ; 
the power of voluntary control is lost, and complete muscular resolu- 
tion takes place, and the patient lies unconscious, relaxed ; urine and 
faeces discharging involuntarily. The face is bloated, congested ; the 
lips swollen and purplish in color; the veins of the face and neck dis- 
tended ; the conjunctivae injected, the pupil contracted, no reflex 
movements excited by touching the cornea or titillating the fauces ; 
the breathing slow, stertorous, and shallow, with puffing expiration, 
and the pulse feeble and slow. Such is the condition in severe cases 
of alcoholic intoxication. A man so affected is said to be dead 
drmihy There are, of course, various gradations in the severity of 
the symptoms, in the lesser degrees of drunkenness. In some sub- 
jects, a sudden indulgence in considerable doses of alcoholic fluids — 
an outbreak into a debauch — excites a form of acute mental derange- 
ment — mania a potu, or acute alcoholic delirium* — which is con- 
founded with delirium tremens ; but for the production of the latter 
disease chronic changes due to alcohol are necessary. Acute alco- 
holic delirium, on the other hand, is due to the immediate impression 
of the alcohol on the brain of a susceptible subject — usually a young 
man having strong neurotic tendencies. 

Acute Alcoholic Delirium, or Mania a potu. — This condition is 
usually confounded with delirium tremens. It differs from it, how- 
ever, in that it is the direct result of alcoholic excess, in a subject free 
from the numerous changes of chronic alcoholism. Those suffering 
from this malady have been engaged in a sudden debauch, or have 
drunk liquors very deeply for a comparatively short time. Besides the 
sudden and great excess in drinking spirits, they have usually been 
subjected to some powerful mental excitement, to mental worry, to 
chagrin, etc. Under the influence of these causes, they grow more and 
more excited, become wakeful, lose their appetite, and presently be- 
come the prey of hallucinations. The delirium is similar in character 
to that of delirium tremens, but the trembling is wanting^ the compli- 
cations of the latter are not present, and the termination is earlier. 
The delirium may be as violent as that of delirium tremens, but it is 
not so important, and a prompt cure may be readily effected. It is true, 
now and then, that such a case terminates in mania when occurring in 

* Magnan, " On Alcoholism," translated by Dr. Greenfield. London, H. K. Lewis, 18'76. 



ALCOHOLISM. 



953 



a subject having strong proclivities in that direction. Usually, the 
prompt withdrawal of the offending cause, proper alimentation, and 
cerebral sedatives, as the bromides and chloral, effect a speedy cure. 
In such cases, the question of the cessation of the spirits can not be for 
a moment doubtful. The effect being due to the impression of alcohol 
on the brain, no structural alterations having occurred, the obvious 
relief consists in the removal of the cause. 

Cheonic Alcoholism. — From the brief view of the changes wrought 
in chronic alcoholism, before given, it is sufficiently evident that these 
changes may be comprehended in two groups, sclerosis and steatosis. 
In the brain and nervous system, as elsewhere, disorders develop, indi- 
cating the greater or less progress in these morbid processes. In the 
intellectual, motor, and sensory sphere are they alike exhibited. With 
the progress of the affection, the memory grows weaker, the judg- 
ment becomes less accurate, and the power of attention and of associ- 
ation of ideas greatly diminishes. Hence the puerilities of thought, 
the rambling and incoherence which are characteristic of the alcoholic. 
His moral sense is blunted ; his duties to his family and to his busi- 
ness are neglected ; he grows indifferent to his personal appearance, 
and becomes dirty in his habits. To remove the feelings of discomfort, 
which come on when the influence of the spirit declines, a constantly 
increasing quantity is necessary. He becomes dejected, morose, and 
irritable, and more and more stimulant is required to lift him up from 
his wretched moral state. The appetite declines, and is confined to a 
taste for condiments, for stimulating articles, and for those having a 
strong, even a biting flavor. The stomach becomes intolerant of food, 
and vomiting frequently occurs. Especially does the alcoholic suffer 
in the early morning before the morning dram gives steadiness to his 
nerves and tone to his stomach. There is, then, much straining and 
retching, only some glairy mucus and a little greenish matter com- 
ing up after great anguish. The mind becomes more and more im- 
paired, the conversation is a maudlin rambling, and ultimately the 
mental condition declines into imbecility. 

As regards the exterior of the body, chronic alcoholics exist in two 
types : the pallid, flabby, but fat ; the red, even purplish-hued, and 
bloated — the former having a smooth, pallid, heavy, and imbecile ex- 
pression ; the latter, roughened by pimples and stigmata, dusky, with 
great bladders under the eyes, yellow and injected conjunctivae, and 
lips blue and swollen. Before these external features are well marked, 
the symptoms produced by the anatomical alterations occurring in all 
parts of the body are developing. The chronic alcoholics experience 
disturbances in the functions of various organs. They have more or 
less headache, or a sense of weight and oppression in the head, ring- 
ing and drumming sounds in the ears, and attacks of dizziness or 
actual vertigo. Vision grows dull, objects float before the eyes, they 



954 



DISORDERS OF NUTRITION. 



see flashes of light, and especially when about to fall asleep. Tremor 
now begins to be manifest, first probably in the lower extremities 
(Anstie), but soon occurring in both ; at first under control, so that a 
strong effort can quiet the muscles, but presently becoming uncon- 
trollable. The trembling is conspicuously worse in the morning be- 
fore the drink and food have had time to support the waning power. 
Numbness, tingling, paresis of the muscles, occurring in one member, 
or on one side, and of brief duration, are not uncommon. Sudden 
attacks of vertigo, with instantaneous loss of voluntary control, the 
patient falling, with or without loss of consciousness, are sometimes 
experienced. With such attacks there may be twitchings of the mus- 
cles of the face or of a member, when, of course, the seizures wear an 
epileptic aspect. Hallucinations are experienced at this period at the 
moment of falling asleep or on awaking. When the alcoholic subject 
has attained to this degree of development of his disorder as manifest 
in these nervous symptoms, and in the state of his bodily nutrition as 
already described, he presents characteristic symptoms of disorders of 
digestion. The tongue may be heavily coated, or glazed and fissured. 
The breath is fetid from the presence of products of alcoholic decom- 
position. The appetite for ordinary food is almost lost, and much 
distress is experienced after eating, but especially in the early morning. 
Vomiting of blood is not infrequent. The stools are much altered in 
character, are often fetid, black and tar-like in consistence, and not sel- 
dom consist of blood. Haemorrhoids form and often bleed freely, and 
sometimes fistula in ano occurs. In consequence of the obstructive 
changes in the liver, ultimately effusion takes place in the abdomen 
(ascites), and oedema in the lower extremities. When haemorrhages 
occur from the intestinal mucous membrane, ascites is not so likely to 
develop. Sclerotic and steatose changes occur in the heart ; the cavi- 
ties are apt to dilate ; calcareous deposits take place in the valves ; 
the great vessels and the intra-cranial vessels undergo atheromatous 
degeneration, and cerebral haemorrhage is one of the results which 
may be expected under these circumstances. Sclerosis and fatty 
changes may also occur in the kidney, and albuminuria result. 

Chronic alcoholism tends to develop several distinct morbid states : 
an acute exacerbation called delirium tremens ; acute alcoholic mania ; 
acute alcoholic melancholia ; dipsomania ; acute alcoholic pneumonia. 
These require separate consideration, and with the fullness demanded 
by their relative importance. 

DELIRIUM TREMENS. — CauseS. — In the greatest number, deliri- 
um tremens is due to the action of the alcoholic fluid ; it is an acute 
alcoholic delirium due to an unusual consumption of spirits by the sub- 
ject of chronic alcoholism. In a smaller number, it is caused by the 
sudden withdrawal of the accustomed stimulus ; the stomach is dis- 



ALCOHOLISM. 



955 



turbed, food and drink are rejected, and hence fhe nervous system is 
left unsupplied. An attack may also be induced by some strong 
moral emotion or excitement, or by an accident or injury. 

Pathological Anatomy. — The anatomical alterations are those of 
chronic alcoholism. The brain has the appearance characterized by 
morbid anatomists as the " wet brain " — that is, there is much fluid in 
the subarachnoid space, in the ventricles, and at the base, and the 
veins and sinus are distended, the substance of the brain itself being 
more or less oedematous. In some instances there is active hypersemia, 
the red points are more numerous, and vessels not seen in the normal 
condition become prominent. Meningitis, cerebral haemorrhage, etc., 
may be present as complications. The most important complication 
is, however, pneumonia. The condition of hypostasis should not be 
confounded with hepatization. Renal changes are by no means in- 
frequent. 

Symptoms. — A continuous debauch may inaugurate the symptoms, 
or the stomach become very irritable, the appetite is lost and even the 
drink is rejected. The trembling characterizing the ordinary state 
increases ; the manner grows excited and irritable, and the coun- 
tenance, before dull and apathetic, now appears animated and restless. 
Insomnia is an early symptom ; but snatches of sleep are obtained, or 
the night is passed in the vain effort to get a moment's repose. Then, 
the characteristic hallucinations and illusions come on. A patient of 
the author's, while apparently well, began to suffer from wakefulness, 
and, coming to him in the hurried and excited way characteristic of 
this state, said, with an air of mystery but of entire conviction, " It's 
most extraordinary," taking off his hat, " but the story of the garden 
of Eden is all dramatized on my hat," and he proceeded to point out 
with much eagerness each detail, until I startled him by declaring it 
an hallucination. Yery often, for several days, such a patient will be 
about, under the influence of some illusion in regard to his own occu- 
pation, or to some public or private affairs, or of some extravagant 
delusion. Sometimes his notions are gay and pleasing, and he is all 
hilarity, but more frequently they are gloomy and frightful. The 
beginning of the delirium is usually at the moment of falling asleep, 
or in awaking, when the insomnia first occurs. He then sees fright- 
ful objects^ — goblins, demons, and monsters — but, fully awake, they 
vanish, and he is able to appreciate his real position. This preliminary 
state is often called " the horrors." With the progress of the case the 
hallucinations become constant. The condition is that of fright ; the 
patient is menaced by persons, or demons, who take his life and he 
seeks to escape. As any one may assume this shape, such a patient 
may be dangerous, for, although the delirium is cowardly and he seeks 
to escape, he may, on a sudden, if he have a weapon, do some mis- 
chief, or he may cast himself from a window. He sees objects on 



956 



DISORDERS OF NUTRITION. 



the wall, tlie figures of the paper appearmg as snakes or devils, and 
they threaten and mock him. The figures on the coverlet appear as 
insects and snakes, and he tries to toss them off, or escape them. He 
j)eers furtively in the corners, and, rising up suddenly, looks under 
the bed. His eye rapidly glances about the apartment, and has a 
troubled and suspicious expression. He may be noisy and furious, 
yelling and screaming incoherently, fighting all who approach, and spit- 
ting out his food and drink. The quiet, cowardly and shrinking pa- 
tients are usually controlled by firmness on the part of physician and 
attendants, but the more furious and maniacal may require the cami- 
sole. Besides the visual, there may be illusions of smell, the patient 
perceiving disgusting odors, and he may go about the apartment snuf- 
fling. Another has illusions of hearing, strange voices mocking or up- 
braiding or threatening him. In fact, the forms which his morbid 
fancies take are almost endless. The morbid activity increases the 
rate of circulation and excites sweating ; but more or less fever comes 
on after a preliminary stage of depression. This stage of depression 
is characterized by a cold, clammy skin, a feeble pulse, and general 
muscular weakness. Fever then slowly develops ; the temperature 
rises in some cases to 105° Fahr. (Magnan) ; the pulse becomes rapid, 
and is marked by an extreme dicrotism. The tongue is moist and 
tremulous, sometimes coated heavily, more frequently is merely pasty. 
The stomach continues irritable, and food, if swallowed, is rejected ; 
but usually difficulty is experienced in feeding these patients, and, when 
delusions of poisoning exist, feeding can be accomplished only by me- 
chanical means. The bowels are apt to be confined. The stools are 
often dark and offensive, sometimes blackish and tar-like. The urine 
is scanty, very high colored, and may contain albumen. 

Course, Duration, and Termination.— The course of delirium tre- 
mens is usually acute. Complications may arise to terminate the case 
in a few days, as a double pneumonia, a cerebral hsemorrhage, etc. ; but 
the ordinary duration rarely exceeds two weeks, by which time recovery 
or death will have taken place. The first stage, as it may be called, 
from the beginning of wakefulness and hallucinations to the rise of 
fever, is very variable in duration, and may last for a week or ten days. 
Convalescence is inaugurated when sleep occurs and the patient awakes 
refreshed, and, taking food, retains it, and at the same time becomes 
clear in mind. Short snatches of sleep, the delusions continuing, and 
food still rejected, do not mark the beginning of convalescence. If 
the delirium subsides, but the patient still mutters and picks at the 
bedclothes, the tongue becoming dry and cracked, and regurgitation of 
dark, brownish and bilious matters taking place, the condition is a bad 
one, and an early fatal termination may be expected. Sometimes death 
occurs suddenly from failure of the heart ; in the midst of active de- 
lirium the pulse becomes rapid and thready, the surface cold and 



ALCOHOLISM. 



957 



clammy, the features anxious and pinched, and death ensues in a few 
hours, or a few minutes even. Sometimes, after waking up from a 
state of forced sleep by narcotics, the patient passes into a condition 
of profound prostration which soon proves fatal. 

Diagnosis. — The symptoms are so characteristic and the history so 
unequivocal, that an error is not likely to occur. Delirium tremens 
may, however, be confounded with its congeners, acute mania and acute 
melancholia, due to chronic alcoholism. The distinction rests on the 
characteristic trembling, the delirium of fear, and the peculiar hallu- 
cinations of delirium tremens, as well as its acuteness. The delirium 
which accompanies alcoholic pneumonia is like delirium tremens, but it 
arises during the pneumonia, whereas, when pneumonia complicates de- 
lirium tremens, it arises during the course of the latter. 

Treatment. — There are two points to which attention must be di- 
rected : to provide suitable aliment ; to procure sound sleep. As the 
stomach is very irritable, milk and lime-water may be given freely but 
at regular intervals. If the attack has occurred in consequence of the 
failure to retain the spirit, it is advisable to give a moderate amount 
of whisky or brandy with the lime-water and milk. In old drunkards 
it is not unfrequently the case that no aliment will be appropriated un- 
less some spirit is given with it. When this condition exists it is in- 
dispensable to allow a moderate quantity of whisky or brandy. Some- 
times an egg will be eaten, beaten up in beer or ale, but more fre- 
quently than any similar compound aliment will egg-nogg or egg-flip 
be readily taken and assimilated. Beef -juice may be given in alterna- 
tion with milk, and, if the stimulant is necessary, can be added to it. 
When the attack of delirium tremens has succeeded to an unusual con- 
sumption of liquors, they should be discontinued, or given in much less 
amount. Here, also, may exist the same state of the digestive func- 
tion, and the same impossibility of procuring assimilation without the 
accustomed stimulant. In fact, in this circumstance lies the solution 
of the problem. Can digestion and assimilation proceed without the 
stimulant ? If so, it is unnecessary — for nothing has been more con- 
clusively established than that the patient does well if he can take and 
appropriate sufficient aliment. The beef -juice or other animal broths 
given should be well fortified by red pepper, which serves a double 
purpose — to stimulate digestion and to act as a cerebral sedative. A 
bolus of capsicum, containing 3 ss to 3 j, every four hours, is now 
known to possess distinct sedative and hypnotic properties, and has 
been successfully used in the treatment of the disease. The notion, 
formerly entertained, that to procure sleep by large doses of opium is 
the only objective point in the treatment of delirium tremens, has hap- 
pily been abandoned, for under this system many patients were either 
fatally narcotized, or forced into a condition of coma vigil terminating 
in collapse. Forcing sleep is secondary to careful alimentation. The 



958 



DISORDEES OF NUTRITION. 



best agent for securing sleep is chloral, or a combination of chloral 
and morphine ; but chloral is not proper when the heart is weak, and 
opium or morphine when the tongue grows dry, and the delirium in- 
creases under its use. If, however, fifteen grains of chloral and one 
fourth of a grain of morphine secure sound and refreshing sleep for 
several hours, the patient awaking free from delusions, they have un- 
questionably done good. In the preliminary stage of " the horrors " 
sleep may be procured by full doses of bromide of potassium. Car- 
diac paralysis has ensued in several cases of delirium tremens, after 
the administration of chloral and bromide of potassium, and fatal 
narcosis by the combination of chloral and morphine. Pilocarpine has 
proved to be exceedingly effective in causing sleep and quieting de- 
lirium. When there is a decided tendency to cardiac failure, and at the 
same time active or furious delirium, tincture of digitalis in drachm - 
doses, or more, is unquestionably very beneficial. Where opium is 
not well borne, or contraindications to it are present, tincture of can- 
nabis indica may be used with advantage. The internal use of chlo- 
roform has acted well in some cases in procuring sleep ; but the in- 
halation of chloroform is very hazardous, and has proved fatal. Be- 
sides the dietetic and medicinal treatment, certain moral considerations 
must have due weight. The subject of delirium tremens should be in 
charge of a resolute and patient nurse. The apartment should be as 
remote as possible from the noises of the outside world. The walls 
should be of a neutral tint, without figures, and the bed-hangings, cur- 
tains, etc., should be perfectly plain and of some subdued color. All 
objects in the room not necessary to the care of the patient should be 
removed ; as little as possible should his attention be attracted by 
coming and going, and all appearance of mystery, such as whispering, 
the exchange of signals, etc., should be avoided. 

Acute Alcoholic Mania is an outbreak of acute mania due to alco- 
holic excess, and to the changes induced by such excess in the condi- 
tion of the intra-cranial organs. The predisposition is inherited. The 
special point in such cases is the tendency to the commission of homi- 
cidal acts. 

Acute Alcoholic Melancholia, like acute mania from the same cause, 
is induced by drink in a subject having an inherited tendency. The 
symptoms present the usual type, and the special characteristic is the 
desire of self-destruction. 

Dipsomania, as the name imports, is that mental condition which 
impels to the drinking of intoxicating liquors. This form of mental 
disorder is the sad inheritance from drunken parents. At the earliest 
period after taste has become differentiated, these unfortunates display 
a strong and special inclination for liquor, and for its exhilarating 
effect, and by the time puberty is reached they are already drunkards. 
In some cases this mental disease manifests itself in periodical attacks. 



ALCOHOLISM. 



959 



characterized by a ferocious and utterly uncontrollable impulse to in- 
dulge to excess in strong drink. These periodical attacks are at first 
separated by considerable intervals, and, beginning at puberty, may 
not seriously impair the tone of the mind and the power of self-control 
until thirty-five, but from this j^eriod on the intervals become very 
narrow, and the entire surrender to alcoholic excess follows at no distant 
time. 

Acute Alcoholic Pneumonia. — The most frequent and fatal compli- 
cation of delirium tremens is pneumonia ; but the latter is very fre- 
quently mistaken for the former. In old alcoholics, an attack of croup- 
ous pneumonia approaches insidiously, and the first symptom indicating 
illness may be the peculiar hallucinations and illusions. Very often 
the hallucinations refer to the difficulty of breathing, the patient main- 
taining that the air is stuffed with something, or that something inter- 
feres with its entrance to his chest. The delirium under these circum- 
stances is comparable to that which comes on in the inebriate after an 
injury or a surgical operation. The pneumonia not being recognized, 
the case appears to be one of delirium tremens. The radical distinc- 
tion between the two affections is this : In acute alcoholic pneumonia, 
the pulmonary disease precedes the delirium tremens and is the cause 
of it ; in delirium tremens, pneujnonia is a frequent complication. In 
the treatment of acute alcoholic pneumonia, the habit of the system 
should not be broken off, but stimulants should be allowed, and they 
may be pushed freely. 

Sequelae of Chronic Alcoholism. — Besides the morbid states which 
may develop during the course of chronic alcoholism, there are sequelae 
which require some consideration. We owe particularly to Magnan * 
the development of our knowledge on this point. It is not difficult to 
comprehend the relation of the various anatomical alterations produced 
by alcohol, and such consecutive maladies as ascites, dementia, general 
paralysis, and the mental disturbance produced by hsematoma of the 
dura mater. Ascites, dementia paralytica, and hsematoma, have been 
studied elsewhere, and the mental enfeeblement produced by atheroma 
of the cerebral vessels has been mentioned in connection with that topic. 
It is merely necessary here to name these sequelae, and to invite the 
attention of the reader to their independent treatment under their ap- 
propriate heads. 

Treatment of Chronic Alcoholism. — For the disorders of digestion, 
morning vomiting, and loss of appetite, accompanied by wakefulness 
and nervousness, the appropriate remedies are abstinence, careful ali- 
mentation, the administration of such tonics as quinine, tincture of nux 
vomica, oxide of zinc, etc., and the use of bromide of potassium to 
procure quiet sleep. In the more chronic cases, where degenerative 
changes may be expected to have taken place, arsenic in small doses 
* " On Alcoholism," etc., London, H. K. Lewis & Co., 1876. 



960 



DISORDERS OF NUTRITION. 



(two drops of Fowler's solution ter in die), the compound sirup of the 
hypophosphites or sirup of the lacto-phosphate of lime, and cod-liver 
oil, are to be strongly commended. The phosphates and cod-liver oil 
should be taken for many months at a time. The chloride of gold 
and sodium and the corrosive chloride of mercury, the author believes, 
have the power to retard the changes in the connective tissue taking 
place in chronic alcoholismus. To effect any obvious results, they 
must be given before the changes are too far advanced, and must be 
continued in small quantity for a long period. With these measures 
must be conjoined a suitable hygiene, proper occupation, and absti- 
nence from alcoholic beverages of all kinds. 

AMYLOID DISEASE. 

Definition. — Amyloid disease is a general condition in which a pe- 
culiar albuminous material is deposited from the vessels into the adja- 
cent tissues. The deposition of this morbid material is usually pre- 
ceded by chronic suppuration in some form. Various names have 
been applied to this disease, as colloid degeneration, lardaceous dis- 
ease, waxy degeneration, bacon-like {specMg, of the Germans) degen- 
eration, etc. 

Causes. — Suppuration, in connection with caries of the bones, long 
continued, is the most frequent cause. By no means so often does 
suppuration of the soft parts produce the same result. Among the 
conditions of this kind are ulcers of the leg of long standing in elderly 
subjects, old fistulse, rectal, urethral, and vesical, but especially empy- 
ema with or without fistulous communication externally, or by a bron- 
chus. Bronchiectasis, phthisical cavities long suppurating, chronic 
abscesses, pyelitis and pyelonephritis, chronic dysentery, etc., have been 
followed, after a more or less protracted course, with amyloid disease. 
The vast extent of suppurating surface in phthisis, when the tubercular 
ulcerations occur in the larynx, bronchi, lungs, gastro-intestinal and 
genito-urinary mucous membrane, furnishes the occasion for amyloid 
disease in a considerable proportion of all the cases — in a majority of 
the cases, according to some observers (Schueppel). It is certain that 
amyloid degeneration is caused by the syphilitic cachexia, especially 
when there are ulcerations and prolonged suppuration in parts of the 
body, more certainly when the bones are affected. Hereditary syphilis 
is also sometimes a cause. There is much reason to believe that a 
protracted cachexia, produced by chronic malarial poisoning, has given 
rise to amyloid deposits. Although it appears necessary that suppura- 
tion be protracted, Cohnheim * has shown that, as regards gunshot 
wounds of bones, three months of suppuration, only, is sufficient. He 
records three cases in which death ensued after wounds of bone, in 

* Virchow's " Archiv," Band liv, p. 271 ; *'Zur Kentniss der Amyloidentartung." 



AMYLOID DISEASE. 



961 



six, five, and three months respectively, the amyloid deposits being 
widely distributed. 

As regards sex, men are much more liable to the disease than 
women — the proportion being from two thirds to three fourths. It 
occurs at all periods in life, but is more frequent at the most active 
and exposed age. 

Pathological Anatomy. — The term amyloid^ or starch-like, is rather 
misleading, since the material is albuminoid in its characteristics. 
The corpora amylacea, as found in pathological products of the ner- 
vous system, present a strong resemblance to starch -granules, but the 
amyloid matter, as deposited in the cachexia, with which we are now 
concerned, is very different in appearance, and " probably has nothing 
in common " with those bodies (Wagner).* 

It has not been possible, hitherto, to separate the amyloid deposit 
from the tissues in which it is deposited ; hence the published analy- 
ses are misleading. It is closely related to glycogen. It has the dis- 
tinctive property that it resists the action of digestive ferments, and 
but slowly yields to putrefactive fermentation. Its presence in tissues 
is readily determined by the reagents originally proposed by Yirchow 
— ^iodine and sulphuric acid. The suspected material is washed over 
with a solution of iodine in iodide of potassium, when the amyloid 
parts are stained of a mahogany brown, the healthy tissue appearing a 
faint yellowish tint. If dilute sulphuric acid (two per cent., Kyber) is 
afterward brushed over, the amyloid matter assumes slowly a dark- 
blue color. The iodide of methylanilin has been brought forward 
lately as a test. Parts of the suspected organ (the liver, for example), 
hardened in alcohol, are placed in a solution of the iodide of methyl- 
anilin, and in a few minutes the amyloid deposits are stained a ruby- 
red, while the rest of the tissue presents a cloudy, bluish tint. This is 
less certain than iodine and sulphuric acid, is the judgment of Kyber. 

In some way, not now understood, the albuminous body, which 
must exist in the blood prepared for tissue-formation, is precipitated 
in an insoluble form in the walls of the nutrient vessels or in the 
tissues adjacent. There are two theories now held in regard to the 
deposits : according to one, the deposits occur in the tissues adjacent 
to the vessels ; according to the other, into the walls of the vessels. 
Just about the vessels, and in their walls, is deposited a thick, color- 
less, waxy material which, as it solidifies, has the transparency, almost, 
of glass. The German name given to it signifies that this material 
resembles lard in appearance. The deposits do not follow any regular 
plan, and are variously distributed in the affected organs. The initial 
deposit takes place in the liver, and in that zone of the hepatic struct- 
ure which is concerned, as is supposed, in the formation of glycogen. 
The brandies of the hepatic artery are first attacked, then the capilla- 

* " A Manual of General Pathology," by Prof. Dr. E. Wagner, op. ciL, p. 325. 
63 



962 



DISORDERS OF NUTRITION. 



ries of the lobules are invaded. According to Yirchow and his fol- 
lowers, the deposits occur in the liver-cells, while Wagner main- 
tains that the capillaries only are invaded, the liver-cells perishing by- 
atrophy and fatty degeneration. Schueppel is inclined to agree with 
Wagner, but Kyber * affirms that the liver-cells are invaded by de- 
posits, as he has isolated them and recognized the changes. As a 
result of the deposits the organ enlarges, sometimes enormously, reach- 
ing the weight in some instances of twelve pounds, and averaging 
twice the weight of the normal organ. The shape is not materially 
altered, except that the anterior edge is smooth, rounded, and thick- 
ened. In color, the organ assumes a light-grayish brown, or yellow- 
ish gray, and in consistence is very firm, resilient, or elastic, giving the 
impression of soft rubber, but not offering much resistance to the knife 
in section, although much tougher than the normal liver-tissue. The 
cut surface seems dry, is nearly bloodless, and has a grayish-yellow or 
brown color, like smoked bacon. The surface is not homogeneous, for 
the outlines of the acini are distinct, and the loblules are separated by 
a yellowish line. When the deposits are slight in extent, the whole 
organ will not appear changed, but in the middle zone of each lobule 
the amyloid infiltration first takes place, and here will be exhibited 
the peculiar grayish color and glassy translucency characteristic of the 
deposit. According, then, to the extent of the infiltration will the 
organ deviate from the normal. Instead of occupying a considerable 
portion of the liver, deposits may occur in spots forming nodular 
masses, the rest of the organ being healthy. Amyloid deposits in the 
liver may be associated with fatty degeneration of parts of the organ, 
with* syphilitic nodules, and with metastatic abscesses. 

In the spleen amyloid deposits are seen in two forms : in isolated, 
small nodules, formed about the Malpighian vessels — the sago spleen 
— and a general degeneration ; the latter being merely a continuation 
and final development of the former. In the true amyloid spleen the 
whole organ is enlarged, firm in its structure, and having a light-brown 
or even grayish-yellow color. The cut surface is smooth and firm, and 
is not broken up into a pulp by pressure, as in the healthy organ. 
The trabeculse are thickened and infiltrated by the amyloid material, 
giving to them the characteristic grayish appearance and vitreous lus- 
ter. The deposits form thick and rather lustrous rings around the 
venous sinuses, and the walls of the larger and smaller arteries are 
infiltrated. 

The amyloid kidney, like the amyloid liver and spleen, is larger 
and heavier than normal. Externally, the cortex is pale, even white, 
from anaemia, and has the peculiar glistening appearance characteristic 
of this degeneration. On section the same appearances are manifest, 

* "Weitere Untersuchungen iiber die amyloide Degeneration," Yirchow's^ "Archiv," 
vol, Ixxxi, p. 1, et seq. 



AMYLOID DISEASE. 



963 



and the broad, whitish, translucent-looking cortex contrasts strongly 
with the dark cones. The vessels of the glomeruli are first changed ; 
then the afferent arteries, and afterward the efferent, become the seat 
of considerable deposits which, however, are most extensive in the 
vasa recta. Subsequently the tubules and their epithelium are infil- 
trated. The supra-renal bodies, in a large proportion of cases — fif- 
teen out of eighteen cases, according to Kyber — are affected in the 
course of the general disease. In extreme cases they are very large, 
pale, and waxy in consistence. The genito-urinary organs, the ves- 
sels of the mucous membrane of the ureters and bladder, of the 
uterus and prostate, and the muscular fibers of these organs, are also 
affected by amyloid change. The vessels of the mucous membrane of 
the tongue, oesophagus, stomach, and intestines, and sometimes the 
mucous membrane itself, are attacked. The arteries of the sub-mucous 
tissue of the intestines and the muscular layer of the stomach and in- 
testines are also affected. 

In a considerable proportion of cases the endocardium and the 
great vessels are affected, as well as the vessels of the body generally. 
The inner coat of the large arteries and the middle coat of the smaller 
arteries and veins are the parts invaded by the deposits (Kyber). We 
possess no information in regard to amyloid degeneration of the ner- 
vous system. 

Symptoms. — When the various organs are affected by the larda- 
ceous disease, a peculiar constitutional state — a cachexia — is induced. 
Previous to the deposition of amyloid matter, the vital forces are de- 
pressed by chronic suppuration, by the syphilitic cachexia, by chronic 
malarial poisoning, etc. Persons attacked with this disease are already 
pale, sallow, thin, weak, and depressed, in varying degrees, according 
as exhausting suppuration or syphilitic lesions or malarial toxaemia 
precedes its development. When the intestinal canal becomes af- 
fected, the appetite declines, there is considerable nausea, sometimes 
vomiting. As changes in the liver occur, hyperaemia and a catarrhal 
state of the mucous membrane are constantly maintained. Under 
these circumstances thrombosis of a stomach- vein may occur, resulting 
in ulceration, usually about the pylorus, and then vomiting of blood 
takes place. An intractable diarrhoea, colliquative in character, also 
comes on. The discharges are thin, offensive, very light or very dark 
in color ; the latter, when blood is present. Particles of food, undi- 
gested and decomposing, are present in the evacuations, and ultimately 
such food as beef -tea, even milk, pass largely unchanged. Sometimes 
the stools appear like rice-water, are mucilaginous, and have little 
odor. 

The clinical feature of amyloid liver is a persistent enlargement of 
the organ. As the weight of the liver, in extreme cases, may reach 
twelve pounds, it is usual to ascertain that the organ extends beyond 



964 



DISORDERS OF NUTRITION. 



its ordinary boundaries, to the breadth of the fingers, or more, below 
the inferior margin of the ribs. When thus enlarged, it can be readily 
felt through the abdominal parietes as of almost stony hardness. Some- 
times the inferior edge of the liver may be grasped, and its condition 
noted, through the relaxed walls. Besides its hardness, the liver feels 
smooth, and is free from tenderness. It is but rare that jaundice oc- 
curs. Ascites is usual, and there may be general cedema or dropsy 
from the accompanying renal lesions. When ascites is alone present, 
there may be oedema of the feet and legs. Often the dropsy assumes 
a high grade ; the abdomen becomes enormously distended, the scro- 
tum attains vast dimensions, and the whole body is flooded with its 
own fluids. 

Another large and hard body — the spleen — can also be made out 
in the abdomen. As the spleen is damaged, the anaemia increases. 
When the deposits are most pronounced in this organ, and when the 
disease begins its course by the changes in the spleen, an increasing 
leucocythemia is the most prominent symptom. When, however, the 
splenic disease is only a part of the general changes, and comes on 
after the lesions are well advanced elsewhere, there will be little 
alteration in the course of the malady except the more pronounced 
angemia ; but in the absence of ascites the splenic tumor may be 
made out. 

The amyloid degeneration of the kidneys is manifest in the changes 
of the urinary secretion. As a rule, the amount of urine passed is 
great, except when a profuse, watery diarrhoea carries off the surplus 
fluid. The urine is, also, pale and of low specific gravity, when 
abundant, appearing to be little more than water. When scanty, the 
urine becomes dark and the specific gravity high. It may thus fluct- 
uate between the extremes 1002 and 1035. The urea, chlorides, and 
phosphates are in very small quantity when the amount of urine voided 
is large, and relatively considerable when the urine passed is small in 
quantity. As the disease progresses, the relative quantity of solid 
matter in the urine diminishes. Albumen early appears in the urine, 
at first occasionally, as a mere trace, but, as the deposits increase, in 
constantly enlarging quantity, although never rising to the percentage 
of certain acute affections. Besides serum-albumen, the urine of amy- 
loid kidneys contains a considerable quantity of globulin. Casts are 
only occasionally found, and are narrow and of the pale, hyaline vari- 
ety. When the urine is condensed, dark in color, and loaded with 
albumen, which is an exceptional condition, the casts will be more 
abundant, chiefly of the narrow, hyaline kind, but also of highly re- 
fracting, yellowish, waxy material. General dropsy is comparatively 
infrequent, while ascites and cedema of the inferior extremities are 
common. Symptoms of ursemic intoxication are only rarely present, 
and for the obvious reason that the elimination of the urinary con- 



AMYLOID DISEASE. 



965 



etituents, including urea, is not materially lessened by the amyloid 
degeneration. Even at the end Avhen the quantity of urine passed is 
extremely scanty, there are but rarely slight symptoms of cerebral 
derangement, including headache, drowsiness, failure of memory, mus- 
cular weakness and tremors, and twitching of the facial and other 
muscular groups. 

Diagnosis. — Amyloid disease, coming on in the course of some 
chronic malady with suppuration, can usually be readily diagnosticated. 
The coincident enlargement of the liver and spleen, the occurrence of 
polyuria with traces of albumen, and the troublesome diarrhoea, make 
up a morbid complexus of a very significant character. The enlarged 
liver may be confounded with the first stage of sclerosis or with echi- 
nococcus cysts. As regards the first, it is to be noted that the history 
is different, but the chief distinction lies in the fact that in sclerosis 
the enlargement is slight and is transient, whereas in amyloid disease 
it is considerable and persistent. In sclerosis the liver is iiTcgular in 
outline and somewhat tender ; in amyloid disease it is hard and with- 
out tenderness. The renal affection of amyloid disease may be con- 
founded with interstitial nephritis. The history of the case becomes 
very important as a means of differentiation. In sclerosis of the kid- 
ney the albumen is more abundant ; a marked reduction in the amount 
of urine, after a considerable increase, is observed ; and cerebral symp- 
toms are much more constant. The character of the casts, and espe- 
cially the appearance of the yellow, highly refracting casts, responding 
to the iodine reaction, are of great value in the differentiation. 

Treatment. — There are obvious indications for treatment in the 
debility and wasting with which the disease begins and is attended 
throughout its course. A full diet, rich in all the materials of nutri- 
tion, and especially of fats, should be prescribed. As the intestinal 
canal may be much damaged, foods converted into peptones in the 
stomach, and the aids to stomach digestion, acids and pepsin, are nec- 
essary. For the diarrhoea, two or three drops of Fowler's solution and 
twice the quantity of tincture of opium, persistently used, are probably 
the most efiicient remedy. Hope's mixture, or an extemporaneous com- 
bination of nitro-muriatic acid and tincture of opium in camphor- 
water, may be substituted. Bismuth in full doses, with aromatic pow- 
der, is a useful astringent. Without a careful regulation of the diet, 
no remedies will succeed. Cod-liver oil, as a food and restorative, will 
sometimes improve the diarrhoea. As remedies for the local deposits 
— to convert the insoluble albuminous material into a soluble — phos- 
phorus, the phosphites, and phosphates, are, in the author's experience, 
entitled to the first place as remedies. Phosphorus in minute quan- 
tify (t^o gi'^i^)) dissolved in cod-liver oil, is probably first. Phos- 
phites, in the form of the compound sirup, is a valuable combination. 
The phosphates rank next. The author has had excellent results from 



966 



ANIMAL POISONS. 



the phosphate of soda in cases without diarrhoea, which is a contra- 
indication to its use. These remedies should be used persistently and 
for lengthened periods. The iodide of potassium, with a generous 
diet and iron, is a method of treatment strongly urged by Bartels, and 
with which he has, he says, succeeded in effecting a cure. A careful 
mercurial course, with or without conjoint or alternate administration 
of the iodide of potassium, may be useful in cases originating in the 
syphilitic cachexia. Dickinson, influenced by his theory of amyloid 
deposits, administers alkalies, which restore their solubility. Alkalies 
may be serviceable, but the depression caused by them should be pre- 
vented by the timely administration of iron and a generous diet. 



ANIMAL POISONS. 



HYDROPHOBIA. 

Definition. — Hydrophobia is a specific disease due to the inocu- 
lation of a poison contained in the saliva of rabid animals, notably 
the dog, and characterized by pain and stiffness of the inoculated 
part ; by exaltation of the reflex faculty ; by spasms of the throat 
on the attempt to swallow, and subsequently at the sight of liquids ; 
by delirium, exhaustion, and death. It is also known as rabies 
canina. 

Causes. — The sole condition necessary for the causation of hydro- 
phobia is the inoculation of man with a contagious principle contained 
in the saliva of the dog, cat, wolf, and some other rabid animals. This 
principle is not absorbed through the unbroken skin, but from a wound 
or abrasion. A certain predisposition is also necessary, it is probable, 
for, of all bitten by animals unquestionably rabid, but a small propor- 
tion are attacked by hydrophobia. The proportion is variously stated 
from five to fifty per cent., but, while the former is much too small, the 
latter is excessive. Accident more than predisposition is, however, the 
real cause of the exemption of so many who are bitten. The teeth, 
in inflicting the wound, pass through clothing, which removes the 
saliva, and hence the most of those bitten through the clothing escape 
infection. On the other hand, wounds of exposed parts, or an abrasion 
receiving the saliva, is very certain to be followed by the disease, un- 
less there be a decided insusceptibility to the action of the poison. All 
ages and both sexes are liable, but more men than women are attacked. 



HYDROPHOBIA. 



967 



because the former are more exposed. Various moral impressions 
favor the occurrence of the disease. These are apprehension, fear, 
excesses of all kind, fatigue, etc. 

Pathological Anatomy. — There are but few changes found post 
mortem really typical, if any such exist, but are common to all the 
diseases of the same group. The cadaveric rigidity is well marked ; 
there are extensive suggillations, and putrefaction soon begins ; the 
coloring matter of the blood stains the vessel-walls, and the blood 
itself is fluid and has a violaceous color. These facts only indicate a 
changed state of the blood common to many maladies. The fauces 
are red and swollen, the salivary glands enlarged ; the trachea and 
bronchi are hypersemic and contain a quantity of frothy mucus ; the 
lungs are also hypersemic and sometimes oedematous. More or less 
cojngestion of the brain, effusion into the ventricles, and hyperssmia, 
with enlargement of the vessels of the medulla oblongata, have been 
observed. In some cases changes of texture, softening, etc., have been 
seen at the apparent origins of the seventh, eighth, and ninth nerves. 
The pneumogastric, phrenic, and sympathetic nerves have also been 
found in a more or less hypersemic state. 

Symptoms. — The period of incubation is by no means confined to 
fixed limits. In 214 cases collected by Jaccoud, the period of incuba- 
tion was less than one month in one fourth of the number, from one to 
three months in 143, from three to six months in 30, and from six 
months to a year in 11. According to Gamgee, in the large ma- 
jority of cases, the period of incubation is four to eight weeks. Age 
apparently affects the duration of this period. Thus in nine new-born 
infants, the incubation period was thirteen to fifteen days. A very 
remarkable case has been reported of a man two years in prison, who 
had hydrophobia, and who had been bitten seven years before. During 
the period of incubation there is nothing in the wound, nothing in the 
state of the organism, to indicate the existence of any mischief. The 
wound or abrasion may be very slight, may have healed long since and 
been forgotten. At the termination of the incubation, the attention of 
the patient is attracted to the wound by some uneasiness felt in it. If 
it has not healed, the wound takes on a livid appearance, and becomes 
exceedingly painful, the pain shooting toward the trunk from the ex- 
tremities if the wound is so situated. If the wound has cicatrized, the 
scar becomes painful, red, irritable, swollen, and sometimes exudes a 
bloody serosity. Sometimes a sensation of coldness and of numbness 
is felt in the bitten member, and occasionally the lymphatics of the 
limb are swollen, and marked by hard, red lines. The local symptoms 
are soon accompanied by systemic disturbances. The patient is de- 
pressed, apprehensive, peevish. So marked is the condition of melan- 
choly that the first stage of hydrophobia has been called the stadium 
melancholicum. The skin becomes hot, the pulse rapid and bounding. 



968 



ANIMAL POISONS. 



The appetite goes, and the bowels are confined. In some few cases 
the wound continues unaffected, and the feelings of anxiety and alarm 
are absent, the only symptoms coming on being the fever and the gen- 
eral distress belonging to the feverish state. What form soever this 
initial stage assumes, it is of short duration, continuing but a few hours 
or a day or two. The peculiar reflex paroxysms then come on : the 
breathing is sighing and jerking, the epigastrium is elevated by the 
forced depression of the diaphragm, and the shoulders are rendered 
prominent by the overaction of the levator and trapezius, while at the 
same time there is experienced a sensation of prsecordial oppression 
and of tension in the anterior wall of the thorax. The neck grows 
stiff, the throat feels constricted, and the movements of the head are con- 
strained. 'Now are experienced the peculiar sensations which are so dis- 
tinctive of the disease. A spasm seizes the pharyngeal muscles when 
any attempt is made to swallow. The patient has an intense thirst, but 
whenever he approaches the cup to his lips his countenance assumes a 
strange expression, the eyes stand prominent, the features contract, the 
limbs tremble, and especially his hand carrying the cup, and he tries 
with a sudden movement to gulp down the liquid, but he can not pass it 
into the pharynx ; it is violently rejected with a suffocative spasm, and 
he falls back on the bed exhausted. Presently, the appearance of water, 
the reflection from a mirror, any impression suggesting the act of swal- 
lowing, throws him into a state of apprehension or excites pharyngeal 
spasm. Meanwhile a sense of constriction continues at the throat, the 
mouth is dry and parched, and he is continually impelled to eject from 
his fauces, with a harsh, barking hawk, some viscid saliva. It is this 
hawking which is vulgarly supposed to be the bark of a dog. It must 
be admitted that this is a peculiar, unearthly hawking, which, under 
the circumstances, might seem like the bark of a dog. The appearance 
of the patient at this time is most striking. He is restless, his counte- 
nance anxious, his eyes bright and wandering ; he becomes garrulous, 
and his mind presently wanders, and every few minutes he hawks and 
pulls at his throat as if to remove some obstruction. He will not toler- 
ate the suggestion of liquids, much less their approach, and assumes a 
hostile attitude if there is a persistent attempt to induce him to try to 
drink. On the other hand, the mind may be clear, but this must be 
regarded as exceptional, for, in all the cases seen by the author, the 
patients, if not maniacal, were at least disordered in mind. Cases have 
been reported, however, in which the faculties of the mind were pre- 
served, in which the patients not only were fully aware of their des- 
perate condition, but expressed the greatest solicitude for their families 
and for those about them. The author has heard of one case in which 
the patient voluntarily asked to be restrained during the paroxysm, 
that he might not do injury to his attendants. There ensues such an 
exalted condition of the reflex faculty, at last, that a breath of air will 



HYDROPHOBIA. 



969 



excite tlie paroxysms, whicli are not unlike those of tetanus. When 
they come on, respiration is jerking, and then fixed, the voluntary 
muscles are rigid, breathing is suspended, the surface becomes red and 
cyanosed, and the action of the heart is rapid and weak. They last 
but a few seconds at first, but increase in duration and severity, and 
are excited by less and less powerful impressions toward the end. 
Sometimes there are severe and persistent erections (priapism), and in 
women there is nymphomania. Difiicult urination is not uncommon, 
and in some cases strangury is present. 

Course, Duration, and Termination. — Hydrophobia is a very acute 
disease. The first stage does not exceed two or three days, and may 
be but a few hours in duration, the average being about one day. The 
duration of the second or hydrophobic stage is similar ; it may last 
two days, possibly three, but it is usually ended in one, sometimes in 
a few hours. The termination may be by exhaustion, the under jaw 
drops and the saliva flows from the corner of the mouth ; the pulse 
becomes small, weak, and thready, the body is covered with a cold 
sweat, the pupils are dilated, the eyes fixed, the voice fails, and the 
patient, after a short, convulsive trembling, passes into collapse, and 
dies. In other cases the patient dies asphyxiated in the paroxysm. 
In still others, general convulsions end the case. The whole duration 
of the disease is comprehended in about three days. The prognosis 
of hydrophobia is most unfavorable, no cases of the genuine disease 
having ever recovered, unless we may except two, treated with woo- 
rara, lately reported. 

Diagnosis. — There is a strong resemblance between tetanus and 
hydrophobia : in both the reflex function of the spinal cord is highly 
excited, in both slight peripheric irritation excites spasms ; but they 
differ in that hydrophobia follows a bite of a rabid animal after a 
long period of incubation, and tetanus is caused by a wound ; in 
hydrophobia there is a sense of constriction of the fauces — in tetanus 
there is trismus ; hydrophobia is of much shorter duration than teta- 
nus, is invariably fatal, while a considerable proportion of the cases 
of tetanus get well. Hydrophobia may be confounded with an hyster- 
ical malady simulating it, but the latter is accompanied by other hys- 
terical symptoms, does not prove fatal, and there is no history of the 
bite of a rabid animal. There are those who maintain that hydropho- 
bia — as a disease due to a peculiar poison contained in the saliva of 
the rabid dog— has no real existence ; that the poison is a fiction, and 
that the symptoms supposed to be produced by it are really due to 
the influence of sympathy, to the faculty of imitation, and to the 
imagination, the whole being intensified by morbid fears. It would 
seem impossible, on this hypothesis, to account for the occurrence of 
this disease in infants after being bitten. As, however, the imaginary 
disease is just as fatal as the supposed genuine affection, the practical 



970 



PAKASITES. 



physician will be indifferent to the theories, and will be as loath to en- 
counter the one as the other. 

Treatment.— When the bite of a rabid animal has been received, 
the wound should be scarified, cauterized with a hot iron, or every 
part of it touched with nitrate of silver. The success of Mr. Youatt 
has been so great with the nitrate of silver that severer applications 
would seem to be unnecessary. Permanganate of potassium, having 
succeeded so well in the bites of venomous snakes, should be tried. 
There is no specific to prevent the disease, and we are equally ignorant 
of a remedy to cure it, unless Pasteur's inoculations with the modi- 
fied virus prove to have the effect which he claims for the method. 
Of all the remedies hitherto proposed, curare is the only one which 
seems to possess any power over hydrophobia. Two cases have been 
reported recently — one in Italy and one in New York — in which a dis- 
ease, diagnosticated as hydrophobia by eminent practitioners, got well 
under the hypodermatic injections of curare. Chloral, chloroform, 
gelsemium, nicotine, etc., may be used to alleviate the distress. 



PARASITES. 



TRIOHINiE AND TRICHINOSIS. 

Trichina. — This dangerous parasite is found in two forms, as the 
intestinal trichina which is sexually mature, and as the muscle trichina, 
not fully developed, or sexually immature. The name given by Pro- 
fessor Owen [Trichina spiralis) is based on the hair-like appearance of 
the parasite and the spiral form assumed by it in the muscular tissue. 
It is a very small, hair-like worm, having a head smaller than the rest 
of the body, while the caudal extremity is rounded. The females are 
three or four millimetres long, and contain a sexual apparatus consist- 
ing of an ovary, a uterus, and a vagina. Only a part of the sexual 
apparatus exists in the muscle-trichina, the rest being developed after 
the parasite has entered the intestinal canal of its host. It is vivipa- 
rous, and discharges from the vaginal outlet about one hundred em- 
bryos a week, and the birth of the embryos begins in about a week 
after the female enters the intestine. As more females than males are 



TRICHINOSIS. 



971 



born, and as successive formation of embryos from the eggs may take 
place,* the number developed becomes enormous. The male trichina 
is one half the size of the female, and contains at its caudal extremity 
the sexual apparatus. The viable embryos discharged from the female 
are in lively motion. They do not remain in the intestine, but begin 
a process of migration which only terminates when they have reached 
their habitat in the voluntary muscles. The manner of reaching their 
destination is not known — whether by the blood-vessels, by the lymph- 
channels, or by direct effort boring through the inters^ening tissues 
until the muscles are reached. As they have repeatedly been found in 
the blood and lymph,f and in the connective tissue only adjacent to 
muscles, J and as the rate of migration is so rapid, it seems pretty cer- 
tain that the distribution is chiefly passive by the blood and lymph- 
streams. Endowed with a strange instinct, these parasites, when they 
reach the muscular tissue, stop their wanderings, pierce the muscles, 
and force their way into the primitive fasciculi, where they coil up. 
The sarcolemma of the primitive fasciculus now undergoes thickening, 
a quantity of granular matter surrounds the parasite, and a number of 
" oval, vesicular-shaped muscle nuclei " § develop on the inner surface 
of the capsule formed by the thickened sarcolemma. In the process of 
transplantation of the parasite from the intestinal canal to the muscle, 
the parasite grows ; but it reaches the greatest size in fourteen days 
after it is established in the muscle. In the intestinal canal the em- 
bryos have a very short lease of life (five to eight weeks) ; but, safely 
deposited in the muscle, they continue during the life of their host 
and for a short period after his death. In the muscles, after a time, 
the trichinae undergo a further change. Lime-salts are dejDOsited in 
and about the capsule, and ultimately in the parasite itself, when mi- 
nute bits of lime, just visible to the eye, are seen more or less thickly 
distributed through the muscular tissue. The distribution of trichina 
is determined by the migrations of its hosts — the hog, the rat, and 
man. This parasite has been found in the cat and other animals, and 
has been artificially reared in rabbits and Guinea-pigs. In the dog, 
however, it appears to develop no further than intestinal trichina, mi- 
gration of the embryos not taking place in this animal. As man and 
the other hosts of the parasite are to be found everywhere, so this par- 
asite is universal. It is especially frequent in this country in the great 
West, because of the enormous extent of the pork-traffic. The pro- 
portion of hogs infected in the West is variously stated, but it is prob- 

* Cohnheim, " Zur pathologischen Anatomie der Tnchinenkrankheit," Tirchow's " Ar- 
chiv," Band xxxvi, p. 163. 

f Yirchow, ibid., Band xxxii, s. 332, " Zur Trichinenlehre," contains also a full his- 
torical account of progress of discovery. 

X Ibid., Band xxxiv, s. 469. 

§ Heller, Ziemssen's " Cyclopaedia," article " Migratory Parasites," vol. iii. 



972 



PARASITES. 



ably not an exaggeration to say that from one to twenty per cent, 
contain trichinae.* 

TricMnosis. — The symptoms produced by trichina, when these para- 
sites reach the body of man, are entitled trichinosis. They are not 
very uniform, but a division into stages, based on the several steps in 
the life-history of the trichina, will be convenient. These stages are 
the intestinal, the migration, and the encapsulation. When a piece of 
pork, containing in every cubic inch eighty thousand (Dr. Sutton) tri- 
chinae, is swallowed, these parasites are set free ; they then complete 
their sexual development, and, as each female discharges a hundred em- 
bryos, the intestinal canal soon contains thousands. If few in number, 
there may be but little disturbance of the canal, but usually more or 
less irritation of the stomach and intestines follows in a short time 
after the infected meat is swallowed. In a few hours or in a day or 
two, some uneasiness of the stomach is felt, and in some cases severe 
attacks of neuralgia of the solar plexus ; nausea comes on, and then 
vomiting occurs. The vomiting may end with the first effort which 
empties the stomach, or it may continue with much retching and an- 
guish for several days. The mouth feels pasty, and a subjective sense 
of foul odor is also experienced. Intestinal uneasiness comes on with 
the irritability of the stomach ; colic, more or less distention of the 
abdomen, and diarrhoea follow. The stools, at first composed of faeces 
merely, become watery, light in color, and may ultimately assume a 
nearly rice-water appearance. This symptom is more persistent than 
the vomiting, may continue, indeed, for several weeks, and is apt to 
be exhausting. Diarrhoea may alternate with constipation ; in some 
cases there is constipation only. When the digestive disorders have 
persisted for several days, fever comes on in the usual way, preceded 
by shivering or a chill. It is probable that the fever is about coinci- 
dent with the birth of the embryos and the beginning migration. The 
fever is remittent in type in the sense that typhoid fever is, which it 
closely resembles. In some cases the type is truly remittent, with a 
decided morning remission and an evening exacerbation. The pulse is 
quick, rather small, and early shows a tendency to weakness, the range 
being from 90 to 140. There is intense thirst, the tongue and lips are 
dry, and the face is red and swollen (Davaine). During the existence of 
these symptoms the muscles of the body generally are sore to the touch 
and are flabby, but this state must not be confounded with that con- 
dition of the muscles caused by the migration of the parasites into 
them (Heller). The migration period is especially marked by the in- 
vasion of the muscles. The symptoms due to this invasion do not occur 

* The reader is advised to consult an excellent paper by Dr. Sutton, of Aurora, Indiana, 
giving an account of an outbreak of trichinosis, and some general remarks on the propor- 
tion of trichinous pork, which he puts at three to sixteen per cent, for southeastern 
Indiana. (Reprinted from " Transactions of the Indiana State Medical Society.") 



TRICHINOSIS. 



973 



earlier than the tenth day, which allows three days for the migration 
from the intestine. The muscles are affected to varying degrees of 
severity, doubtless, according to the number of parasites entering them. 
There may be only a little soreness, but in decided cases, as might be 
expected, the muscles are hard, swollen, and very tender. The muscles 
of the extremities, especially the flexors, are penetrated, but those of 
the trunk also, only to a less extent. In consequence of this, the mus- 
cles are the seat of violent rheumatoid pains, and motion increases the 
distress. Hence the patients lie motionless, with the limbs semiflexed. 
As the muscles of mastication and deglutition are also invaded, chewing 
and swallowing become difiicult and painful ; hearing is impaired be- 
cause of invasion of the stapedius muscle, and vision may be double or 
distorted because of the penetration of the ocular muscles. (Edema of 
the eyelids is one of the first symptoms of this period, and subsequently 
cedema of the extremities and effusion into the peritoneal cavity ap- 
pear. For the same reason, doubtless, that the voluntary movements 
are impaired, the respiration is embarrassed, and dyspnoea is added to 
the other difliculties, and by the end of the fourth week a general bron- 
chitis, a pleurisy, or a pneumonia may arise to complicate the case.* 
During the development of these formidable symptoms, the mind may 
continue undisturbed ; in fact, a singular apathy takes possession ; in 
other cases delirium occurs, but this may result from the wakefulness, 
the coma vigil, which is so pronounced a feature of the cerebral condi- 
tion in many adults. In children there is a condition of somnolence 
throughout. Various miliary and pustular eruptions appear on the 
skin, which is extremely sensitive, but the most pronounced symptom 
connected with this organ is the profuse sweats which appear early 
and continue throughout the disease. The sweats are not critical, and 
do not modify the temperature. Bed-sores form to a slight extent, and 
desquamation of the cuticle occurs during convalescence. Abortion 
sometimes takes place, but the foetus is free from trichinae ; and, on the 
other hand, pregnancy may continue undisturbed. The menses may 
or may not be interfered with, more usually not. The course of tri- 
chinosis is greatly influenced by the number of parasites. A small 
number may cause a mere temporary diarrhoea ; a large number may 
produce a violent gastro-enteritis, sufficient to cause death without the 
migration into the muscular system (cases by Dr. Sutton). In such 
cases there will occur the symptoms of gastro-enteritis only, and, after 
death, intense hyperaemia, swelling of the mucous membrane, and de- 
struction of epithelium will be seen. The range of temperature in 
these cases is from 98° to 100°, and the type of the fever remittent. 
When migration of a small number of parasites occurs, the fever will 
assume the typhoid aspect, the temperature range from 100° to 104°, 



* Davaine, op. cit, p. 760. 



PARASITES. 



the usual muscular soreness to a small extent be felt, but the most 
pronounced symptoms will be those of inflammation of the gastro- 
intestinal canal. Recovery may ensue in such a case by the encapsu- 
lation of the parasites, and a gradual subsidence of the gastro-enteri- 
tis. From three to four months will be occupied with such a case from 
its beginning to the completion of convalescence. In the severest 
cases all the symptoms given above will appear, and death will take 
place in three to four weeks, frequently caused by pneumonia. The 
mortality from trichinosis will range from twenty to fifty per cent., 
dependent of course on the amount eaten of any given specimen of 
trichinous pork. 

Diagnosis. — Cases of trichinosis are often mistaken for ileo-colitis 
and for typhoid fever. From the former it may be differentiated by 
the oedema of the eyelids, the muscular pains, and the profuse sweats. 
The range of temperature being much the same as that of typhoid, 
the distinction between the two must rest on the muscular symptoms, 
the oedema, the pain and hypergesthesia, the profuse sweats, and the 
absence of the muttering delirium, the subsultus, and other nervous 
symptoms. The oedema occurring in this disease, which is general, is 
separated from cardiac and renal dropsy by the absence of cardiac 
and renal disease, and by the other symptoms pertaining to trichinosis. 
In cases of doubt, the harpoon may be used to take out a bit of mus- 
cular tissue for examination, but this is a measure of doubtful propri- 
ety, because severe gastro-enteritis may ensue without migration. In 
typical cases the harpoon would hardly be necessary, yet Dr. Sutton, 
removing a small piece of the gastrocnemius in one of his fatal cases, 
found it swarming with trichinae, " estimated at more than one hun- 
dred thousand to the square inch," and they were in active motion, 
" coiling and uncoiling." 

Treatment. — Attention should be at once directed to the destruc- 
tion and removal of trichinae in the intestinal canal. A variety of 
remedies have been proposed, but no success seems to have attended 
any of them, unless glycerine may be excepted. The vomiting and 
purging, if not excessive, should be promoted by diluents. Glycerine 
and water, which has the power to cause shriveling and death of the 
parasite, may then be given — one part of glycerine to two parts of wa- 
ter. Carbolic acid may be administered both with the view to allay 
the intense irritation and to act on the embryos. We venture to sug- 
gest a trial of carbolic acid and tincture of iodine for the same purpose. 
Corrosive sublimate, arsenic, picric acid, benzine, and other agents have 
been used to destroy the parasites in the intestines, but without results 
(Haller). Quinine seemed to exercise a good influence in Sutton's cases, 
the best, indeed, of any of the agents used. As this remedy has a 
toxic influence on the low forms of life, it seems desirable to employ it 
more freely in future oases. If constipation be the condition, purga- 



CHYLURIA. 



975 



tives should be administered without delay. The treatment to be pur- 
sued when the parasites migrate, must be purely symptomatic. The 
obstinate wakefulness and the pains will require morphine and chloral. 
Quinine and stimulants will be needed to support the powers of life. 
Milk, beef -juice, egg-nogg, and other aliment must be carefully ad- 
ministered from the beginning. There is but one point in prophy- 
laxis. Meat containing trichinae should be thoroughly cooked. As 
the cases arising from these parasites are caused by the consumption of 
raw hams and raw sausage recently cured, this practice should be 
totally discontinued. 

CHYLURIA. 

Definition. — By the term cJiyluria, it is intended to express a con- 
dition of disease, characterized by the presence of chylous matter in 
the urine. The milky or chylous appearance of the urine is now 
known to be due to the presence, in the blood and urine, of a parasite 
— Filaria sanguinis hominis — or a filaria having the blood of man for 
its habitat. This filaria is a nematoid entozoon, and hence this malady 
is appropriately classified with the parasitic affections. It is often 
confounded with ordinary hsematuria, or bloody urine. 

Causes. — Chyluria is a disease of tropical and sub-tropical regions, 
but cases have been observed in England, and they are not infrequent 
in the southern parts of this country. The West Indies is a favorite 
locality for the appearance of this parasite ; and Brazil — as might be 
expected — has furnished many cases of chylous urine. 

The parasite, to the presence of which, in the blood and urine, the 
disease seems to be due, is a nematoid entozoon having the diameter 
of a red blood-globule (=0-007 mm.) and a length of -f^" (=0*34 mm.) 
(Lewis). The filaria is inclosed in an extremely delicate and transpar- 
ent membranous sheath, and is, when living, employed in movements, 
now coiled, now fully extended. The relation of the parasite to the 
production of chylous urine is not clear, but the constancy of the 
association is undoubted, and various theories have been put forward 
to explain the presence of the lymph-fluid in the blood. By Robin 
and Bernard it is maintained that the state of the urine is due to the 
admission into the blood of the chyle, by means of the agency of the 
parasite. Dr. Carter holds that a direct communication is established 
between the lymph-canals and blood-vessels, but he does not explain 
how the parasite effects this admixture. Dr. Roberts also proposes an 
explanation, by which the chyle gets into the blood through an open- 
ing made by ulceration into hypertrophied lymph-canals. None of 
these theories reconciles all the facts, hence they can not be regarded 
as adequate. The constant presence of the filaria seems now to be 
well established ; but the exact relation of the parasite to the chylous 



976 



PARASITES. 



urine remaiDS to be demonstrated. Besides the filaria, as a cause of 
haematuria, a fluke was discovered in 1851 by Dr. Bilharz, as produc- 
ing the same condition. 

Pathological Anatomy. — No disease of the kidneys has been dis- 
covered, and, indeed, no change in any organ or tissue has been made 
out, that properly pertains to the condition of chyluria. There are, 
however, in all parts of the vascular system — found in the blood, 
venous and arterial — numerous specimens of the filaria. This parasite 
is also contained in the lymph-fluid discharged at any point, and in 
the chylous urine. It follows, therefore, that the changes in the blood 
induced by the parasite are the sole pathological conditions of chylu- 
ria. As this state may exist for many years, various intercurrent dis- 
eases can arise, but then the morbid conditions are independent of the 
chylous state of the urine. 

Symptoms. — It is now well known that there is no constancy in the 
symptomatic expression of chyluria. Nevertheless, it is the intention 
of the author to present as clear an outline, as may be, of the symp- 
toms properly pertaining to this state. 

There may be no symptoms to indicate the onset of the disease, 
until the characteristic chylous urine makes its appearance ; but in a 
majority of cases there occurs some uneasiness in the back, extending 
through the loins, along the course of the ureters, and in the peri- 
nseum. Coincidently with this symptom there are much debility and 
depression of mind. Hypertrophied lymph-vessels may yield, and 
lymph-fluid escape, in the axilla, groin, scrotum, and elsewhere. Oc- 
casionally elephantiasis lymphangiectodes is associated with chyluria; 
or, indeed, true elephantiasis may occur simultaneously. The most 
characteristic symptom, however, is the presence of chylous fluid in 
the urine. When this admixture takes place, the urine has a milky or 
whey-like appearance and odor, and, after standing for some time, 
coagulates, forming a jelly-like mass. If blood is present, as some- 
times happens, the coagulated mass has a reddish hue, or the blood, in 
shreds of coagula, is seen at the bottom of the vessel holding it. 
Sometimes the contained blood coagulates in the bladder, and, ob- 
structing the urethra, suddenly stops the flow of urine. 

The presence of chyle in the urine may be determined by two tests : 
by the use of ether to dissolve out the fatty matter, and by heat to 
precipitate the albumen. When the urine is shaken up with ether, 
the fat is dissolved out, and hence the milky appearance ceases ; when 
boiled and nitric acid added, the albumen present coagulates. It is 
important to note that the quantity of chylous fluid present in the 
urine is not always the same : indeed, under some circumstances it 
may be absent. In different examples of the same disease, and in the 
same case at different times, the quantity of emulsionized fat may vary 
greatly. There may be as much as 1*39 of fat in the urine at one 



CHYLURIA. 



977 



time, and in the same subject, a few hours subsequently, none may be 
detected. The fat and albumen are not always present in the same 
relative proportion. After active exercise, the albumen exists in 
greater quantity, and, after meals, the fatty matter. The latter may 
be nearly entirely absent in the early morning before any food has 
been taken, and must vary in quantity with the proportion of fatty 
matter in the food. Any analysis of the urine must, therefore, be 
considered with reference to the period at which the examination was 
made. In general, it may be said that chylous urine does not cor- 
respond in composition to any of the fluids of the body, but compares 
more nearly to chyle than any other. 

The composition of the blood is, also, altered in chyluria. The 
proportion of fatty matter in normal blood is as 1 to 116 of albumi- 
noids, but in chyluria the fat exceeds the albumen. Although there 
are discrepant opinions, the general truth is in the direction stated. 
Besides the change in the quantity of fat, the blood is not altered, 
except in regard to the presence of the hsematozoon — the Filaria san- 
guinis hominis. The same parasite is found in the urine also. 

Course, Duration, and Termination. — The course of chyluria is es- 
sentially chronic, and no fixed duration can be assigned to any case. 
The disease lasts from one year to fifty years. Now and then a case 
terminates fatally, in a most unexpected manner. The sufferers from 
this malady appear debilitated, and experience a marked degree of 
mental depression. The explanation of these symptoms may be found 
in the presence of blood or chyle in the urine. In some cases, without 
any apparent reasons, the urine assumes a milky appearance, and after- 
ward the general symptoms of depression come on. Indeed, the 
aspects of the malady are Protean, and a proper discrimination is pos- 
sible only by recognizing the filaria in the blood and urine. Even 
before the symptoms appear, sometimes filarise can be detected. The 
prognosis can not be regarded as favorable in any case, since, when a 
cure has been apparently effected, the disease unexpectedly recurs, and 
this may happen many times. 

Treatment. — ISTo curative remedy has thus far been proposed. Gal- 
lic acid, in full doses — a drachm or two daily — has proved useful in 
some cases. Probably carbolic acid and tincture of iodine, alone or 
in combination, will be found to act beneficially. Large doses of iodide 
of potassium have proved beneficial in a few cases. Full doses of 
quinine may have an effect on the growth and development of the 
parasite. The influence of change of associations, of occupation, of 
climate, has not been sufficient to warrant the recommendation of such 
hygienic means. As the chronicity of the cases will permit, the va- 
rious parasiticides may be tried in turn. 



64 



978 



PARASITES. 



DISEASE-PRODUCING MICROSCOPIC ORGANISMS. 

Forms and Characteristics. — There are various parasites which ap- 
pear to have a causative relation to certain morbid processes. Some 
of them have been studied in relation to the diseases produced by 
them ; others remain for separate consideration. 

Vegetable Paeasites. — Parasites infesting the human body be- 
long to the vegetable and animal kingdoms. The former — or vegeta- 
ble parasites — are contained in two classes : the Protophyte or Schi- 
zophyta ; the Zygosporge. Of the former, the order Schizomycetes 
contains the most numerous and important of the vegetable parasites, 
viz., Micrococcus, Bacterium, Bacillus, Vibrio, Spirillum, etc. 

To the second order, the Saccharomycetes, belong the Toruloe and 
the Sarcina Ventriculi. 

Micrococci. — This word signifies a small berry, and is applied to 
a spherical body, highly refractive, of very minute size, never exceed- 
ing and often less than mah. in diameter. They are seen 
as isolated dots in active motion, dividing transversely by fission, or 
form in rows or chains of six, eight, or more, or they are united by 
an intercellular fluid into masses, called zooglvea. They are composed 
of protoplasm, highly refractile, taking up coloring-matters with facil- 
ity, but resisting the action of acids and destructive agents generally. 
They develop most perfectly in fluids containing carbon and nitrogen 
compounds and a small quantity of free oxygen, but air does not seem 
very necessary to their growth, since they develop without it under 
other favorable conditions. 

There are various kinds of micrococci. Only those having patho- 
logical relations need to be alluded to here. It is quite certain that 
micrococci are found in connection with various pathological fluids 
and processes, but it must be admitted, we think, that their exact re- 
lation to these conditions has not been made out. It seems to be well 
established, however, that if micrococci are entirely excluded, putre- 
factive decomposition can not occur in animal substances. It was 
"long ago ascertained by Pasteur that every kind of fermentation (pu- 
trefactive included) is correlative of the growth and multiplication of 
some organism. Infective pus owes any virulence it may possess to 
the presence of these organisms, since it has been shown that fresh pus 
free from these bodies has no infective property. But there are not 
wanting facts on the other side, especially the filtration experiments, 
which seem to prove that the infective quality resides in the fluid con- 
taining the micrococci, rather than in these bodies themselves. Their 
relation to the infective diseases — pyaemia, puerperal fever, diphtheria, 
etc. — must, therefore, be regarded as still sub judice. A peculiar mi- 
crococcus for diphtheria has been described by Eberth, another for 
vaccinia by Cohn and Sanderson, and still others for various maladies. 



DISEASE-PEODUCING MICROSCOPIC ORGANISMS. 



979 



by Klebs and his followers, but it must be admitted by any candid 
inquirer, we think, that the facts do not as yet warrant an authorita- 
tive statement. 

Bacteria. — These are rod-shaped, about the jo-foo of an inch in 
length, plain or jointed. They occur in putrescent or fermenting 
fluids, and vary a good deal in size and shape according to the media 
in which they are found. In decomposing fluids they are smaller, and 
in fermenting solutions larger, than the medium. In the former they 
are know^n as Vihriones, or in larger and longer rods, as Leptothrix ; 
and in the latter they are the well-known Torulce. Some bacteria, 
seem to be entirely without morbific quality, and others, that may not 
be distinguished from them, contain an intense virus, or, if they do 
not contain it, have the power to produce it. 

Bacillus. — The term bacillus signifies a staff, and is now applied 
to a filiform bacteria. Bacilli have been found of late in great num- 
bers in certain infectious diseases, notably in splenic fever and malig- 
nant pustule. More recently, a peculiar bacillus has been detected by 
Koch in tubercular exudations and deposits — the J^acilliis tuberculosis. 

Spirillum. — This term is applied to the spiral form of bacteria. 
Cohn, who has made the most careful study of these organisms, and is 
the highest authority on them, divides these sj)iral bacteria into three 
forms : 1. Vibrio^ which consists of short spiral filaments, very flexi- 
ble ; 2. Spirillum, also filaments, but rigid ; 3. Spirochete, long, spiral, 
flexible filaments. The last-mentioned form was described by Ober- 
meier as existing in the blood of relapsing fever during the paroxysms, 
and his description has been abundantly confirmed. It is sometimes 
called Spirochoete plicatilis, as it is an identical form with that de- 
scribed by Ehrenberg under this name. 

Animal Parasites. — Many of the animal parasites have been con- 
sidered in relation to the diseases caused by them. There are, how- 
ever, some remaining for examination, which are partly of a practical, 
partly of a scientific interest. Under the name chyluria, mention is 
made of the Filaria sanguinis hominis, a parasite discovered by Dr. 
T. R. Lewis. An endemic hsematuria occurs at the CS,pe of Good 
Hope and other parts of the African Continent, which is caused by a 
fluke, called after its discoverer. Dr. Bilharz, of Cairo, the Bilharzia 
hoematobia. This parasite is found in the veins of the portal system 
and in the bladder, and causes hsematuria. 

Certain trematode parasites, commonly known as flii7x:es, are some- 
times found in the human body, notably in the liver. About twenty 
cases of distoma hepaticum have been recorded, several by Professor 
Joseph Leidy, M. D., of Philadelphia, and they may therefore be en- 
countered in this country. Besides their usual abode in the liver-ducts 
and gall-bladder, they have been found under the skin behind the ear, 
under the scalp, and in the sole of the foot. 



980 



PARASITES. 



Of greater practical importance to the physicians of this country, 
especially of the Southern States, is the chigoe^ or popularly the jigger 
or sand-flea. The popular notion is so far true that this parasite 
really belongs to the flea tribe, and is named Pulex pe^ietrans. It in- 
habits by preference a dry, sandy soil, and is exceedingly prolific. It 
deserves to have the adjective penetroMs appended to pidex. They 
bore into the skin of the feet, especially under the nails and between 
the toes, where the softer integument permits more ready penetration. 
The impregnated female, thus deposited under the skin, swells to con- 
siderable size, and excites a violent local inflammation, suppuration, 
and sloughing. The larvae also, deposited in open wounds and ulcers, 
excite unhealthy and destructive inflammation. The bones finally 
become diseased, and toes may slough off, or an extremity may be lost 
by a necessary amputation. 

It follows, from these considerations, that when a jigger penetrates 
the skin it should be removed with the utmost care, so that no portion 
of it, or any of its larvae, be permitted to remain behind. If the para- 
site is not successfully removed, its destruction by carbolic acid, or 
sulphurous-acid lotions, should be attempted. 



GElSrERAL IJTDEX. 



A PAGE 

Abscess of the Brain 613 

of the Kidney 564 

of the Liver ISl 

Perinephric 564 

Pharyngeal 22 

Aconitine in Neuralgia 732 

Adenia 229 

Adherent Pericardium 2 S3 

Addison's Disease 235 

uEsthesiometer £63 

Agraphia 623 

Ague-Cake 223, 8S7 

Albuminuria 517 

Alcoholism 950 

Allochiria 569 

Amyloid Disease 96 

Amyloid Kidney 53S, 964 

Liver 195, 964 

Spleen 224, 964 

Amyotrophic Lateral Sclerosis 662 

Anaemia 254 

Cerebral 573 

Progressive Peroicious 262 

Splenica ... 229 

Aneurism, Aortic 336 

of Hepatic Artery 203 

Miliary 5S9 

Angina Pectoris 747 

Animal Poisons 966 

Ankle Clonus 574 

Aortic Insufficiency . . 314 

Lesions 314 

Stenosis 314 

Yalves, Diseases of . . 314 

Aphasia.. 623 

Amnesic 623 

Ataxic 623 

Apoplexy 5S9 

Pulmonary 427 

Appendix Vermiformis, Inflammation of. 86 

Aphthae.. 6 

Arachnoid, Cyst of 598 

Arteritis 332 

Arthritis Deformans 936 

Eheumatoid 936 

Articular Kheumatism 920 



PAGE 

Ascaris Lumbricoides 138 

Yermicularis 141 

Ascites 150, 191 

Aspiration 190, 370 

Asthma 470 

Asthma, Hay 875 

Atelectasis 437 

Atrophy of Nerves 729 

Auditory Vertigo 626 

Autochthonous Thrombosis. 581 

Autumnal Catarrh 875 

B 

Bacillus 979 

Comma 838 

Tuberculosis 406, 979 

Bacteina 979 

Basal Meningitis 605 

Basedow's Disease 749 

Bile, Composition of 162 

Tests for 162 

Bile-Ducts, Catarrh of 210 

Occlusion of 214 

Biliary Calculi 215 

Bilious Fever 895 

Bleeder Disease 243 

Bleeders 244 

Blepharospasm 738 

Blood : its Composition 225 

Examination of. 226 

Blood-forming Organs, Diseases of 225 

Blood-Vessels, Diseases of. 332 

Bothriocephalus Latus 137 

Brain, Abscess of 613 

Anaemia of 578 

Hypersemia of 574 

Syphiloma of 6S6 

Tumors of 617 

Brain and Cord. Diseases of 677 

Multiple Sclerosis of. 677 

Breakbone Fever 831 

Bright's Disease 517 

Bronchi, Stenosis of 469 

Bronchitis, Acute 456 

Capillary 394 

-y- Chronic 461 



982 



GENERAL INDEX. 



PAGE 

Bronchitis, Croupous 465 

Fetid 462 

Humid 463 

Bronctio-Pneumoiiia 894 

Broncho-Pulmonary Haemorrhage 427 

Bronchorrhoea 457, 462 

Brown Induration 432 

Bulbar Paralysis 6-34 

Chronic Progressive 685 

C 

Calculi, Biliary 215 

Eenal 546 

Calomel in Yomiting 71 

Cancer, Colloid 54 

Encephaloid 54 

Scirrhus 53 

of Brain 619 

of Intestines 108 

of Kidney 555 

of Liver 199 

of Lang.... 452 

of Pancreas 159 

of Stomach 52 

Capillary Bronchitis 394 

Carbolic Acid in Yomiting 71 

Catalepsy 712 

Catarrh, Dry 457 

Epidemic 872 

Nasal 499 

Summer 875 

Catarrhal Fever 459 

Pneumonia 394 

Catarrh of Bile -Ducts 210 

of Bronchi 456, 461 

of Duodenum , 75 

of Intestines 66 

of Larynx 476 

of Naso-pharyngeal Space 19 

of Pharynx 21 

ofEectum 87 

of Stomach 33 

Chronic 33 

Caseous Pneumonia 402 

Cerebral Anaemia 578 

Capillaries, Occlusion of 586 

Embohsm 581 

Haemorrhage 589, 632 

Meningeal 590 

Hyperaemia 574 

Sclerosis 677 

Sinuses, Obliteration of 587 

Syphilis 686 

Cerebro- spinal Meningitis 862 

Neuroses 691 

Cervico-brachial Neuralgia 733 

Cervi CO -occipital Neuralgia 783 

Cestoda 132 

Cheyne-Stokes Eespiration 828 

Chicken-pox 771 

Chills aBd Fever 885 

Chiragra 930 

Chloroform Injections in Sciatica 737 

Chlorosis 260 

Cholelithiasis 215 



PAGB 

Cholera Asiatica 838 

Diarrhoea 841 

Morbus 68 

Infantum 71 

Sicca 842 

Typhoid 844 

Cholerine 844 

Chorea 716 

Chyluria 975 

Cirrhosis of the Liver 174. 

Clavus Hystericus 702 

Colic 112 

Biliary 215 

Eenal 546 

Comma Bacillus 838 

Confluent Yariola 768 

Congestion, Cerebral 574 

Spinal 639 

of Kidneys, Active 515 

• of Kidneys, Passive 516 

of Liver 169 

of Lung 377, 483 

Constipation 114 

Constitutional Diseases 755 

Consumption, Pulmonary 401 

Convulsive Tic 788 

Cor Yillosum 275 

Coryza 499 

Cow-pox 768 

Croup 493 

Subsulphate of Mercury in 499 

Pseudo 491 

Croupous Bronchitis 465 

Enteritis 91 

Pneumonia 376 

Cramp, Scrivener's 719 

Cysticercus Cellulosus; 184 

D 

Dandy Fever 831 

Delirium Alcoholicum 952 

Epilepticum 696 

Tremens 954 

Dementia Paralytica 631 

Dengue 831 

Desquamative Nephritis 517 

Diabetes 939 

Insipidus 943 

Diaphragm, Spasm of 741 

Diarrhoea, Acute 78 

Chronic 73 

Digitalis in Heart-Disease 824 

Dilatation of the Heart 296 

of the (Esophagas 26 

of the Stomach 64 

Diphtheria 847 

Diphtheritic Endocarditis 305 

Paralysis 857 

Disseminated Sclerosis 677 

Dropsy of the Abdomen 150 

— of the Brain 601, 

of the Chest 369 

of the Kidney 553 

of the Pericardium . . 285 

Duodenitis 75 



GENERAL INDEX. 



983 



PAGE 



Dura Mater, Haematoma of 597 

Inflammation of. 597 

Dynamograph 571 

Dynamometer , £70 

Dysentery 94 

Dyspepsia 34 

Atonic 89 

Dysphagia 24 

Dystropodextrin 195 

E 

Echinococcus Multilocularis 205 

of ttie Kidney 559 

of the Liver 202 

of th.3 Lmig 454 

of the Spleen 224 

Ecstasy 701 

Electrolysis 207 

EmboUc Pneumonia 392 

Embolism 265 

of the Brain 581 

Fat 587 

Infective 587 

Pigment 586 

Emphysema 440 

Interlobular 440 

Sub -pleural 440 

Substantive 440 

Vesicular 440 

Vicarious 440 

Encephalitis 613 

Endocarditis 801 

Plastic 301 

Ulcerative 805 

Enteralgia 112 

Enteric i?'ever 795 

Enteritis, Croupous 91 

Epidemic Meningitis 862 

Catarrh 872 

Cholera 838 

Epilepsy 691 

Gravior 693 

Alitior 693 

Epistaxis 502 

Ergotin in Leucocythemia 234 

Eruptive Fevers 755 

Diagnosis of 789 

Erysipelas 792 

Essential Anaemia 263 

Eaonymin in Liver-Disease 213 

Exophthalmic Goitre 749 

F 

Facial Paralysis 743 

Fatty Degeneration 290 

Substitution 290 

Heart 290 

Fehhngs Test..... 510 

Fever and Ague 888 

Fevers 795 

Fever, Cerebro-spinal 862 

Intermittent SS5 

Malarial 8S5 

Relapsing 817 



PA6B 

Fever, Eemittent 8S5 

Typhoid 795 

Typhus 812 

Yellow .822 

Fibrinous Pneumonia 376 

Fibroid Kidney 528 

Phthisis , 416 

Fibrous Tissue in Pneumonia 881 

Floating Kidney 562 

Fothergiirs Disease 729 

G 

Gall-stones 215 

Gangrene of the Lungs 448 

of the Mouth IT 

Gaslralgia 41 

Gastritis, Acute 28 

Chronic 33 

Phlegmonous 83 

Toxic 31 

General Diseases 755 

Paralysis 681 

German Measles 778 

Glossitis S 

Glcsso-labio-laryngeal Paralysis 635 

Glottis, (Edema of. 480 

Spasm of 491 

Gmelin's Test 162 

Goitre, Exophthalmic 749 

Gout 930 

Graves's Disease 749 

Green-Sickness. 260 

Grindelia Eobusta in Asthma 475 

Gummata 686 

H 

Hsemocytometer 227 

Haemoglobinometer 227 

Hsematemesis 60 

Haemophilia 242 

Haemoptysis 421 

Haemorrhage, Cerebral 589, 632 

Intestinal Ill 

Nasal 502 

Pulmonary 427 

Spinal 641 

Haemorrhagic Iniarction 311 

Variola 764 

Haematoma of the Dura Mater 597 

Hay -Fever 875 

Asthma 875 

Headache 745 

Heart-Clots . 328 

Heart, Diseases of the 269 

Dilatation of 294 

Hypertrophy of 294 

Inflammation of 287 

Neuralgia of 747 

Palpitation of .,330 

Eupture of. 293 

Valvular Lesions of 309 

Heat-Fever 834 

Heraicrania 745 

Hemiplegia 598 



984 



GENERAL INDEX. 



PAGE 

Hepatic Artery, Aneurism of 208 

Calculi..." 215 

Colic 216 

Hepatitis, Interstitial 174 

Suppurative 181 

Hepatization, Gray STB 

Red 378 

Herpes Zoster 734 

Hiccough 741 

Histrionic Spasm 738 

Hodgkin''s Disease 915 

Hydatids of the Kidney 559 

of the Liver 202 

of the Lungs 454 

of the Spleen 224 

Hydrocephaloid 578 

Hydrocephalus, Acute 600 

Chronic 602 

Congenital 603 

Hydronephrosis 553 

Hydropericardium 2S5 

Hydrophobia 966 

Hydropneumopericardium 286 

Hydropneumothorax 371 

Hydrothorax. 369 

Hyperaemia, Cerebral 574 

Pulmonary 433 

Hypertrophy of the Heart 294 

Hypostatic Pneumonia 434 

Hysteria 699 

Hystero-Epilepsy 701 

I 

Icterus 163 

Ileitis 78 

Ileo-colitis 78 

Infantile Paralysis 664 

Infarction of the Lungs 395, 427 

Infarctions 311 

Inflammation of the Arteries 832 

of the Brain 613, 634 

of the Dura Mater 597, 643 

of the Endocardium 301 

of the Larynx, Acute 476 

of the Larynx, Chronic 478 

of the Liver 174, 181 

of the Lung 876 

of the Pericardium 273 

of the Pleura 355 

of the Spleen 220 

Influenza 872 

Insufliciency, Aortic 315 

Mitral 320 

Intercostal Neuralgia 733 

Intermittent Fever 885 

Interstitial Hepatitis 174 

Nephritis 528 

Intestinal Calculi 124 

Parasites 131 

Intestines, Cancer of. 108 

Catarrh of 66 

Haemorrhage of Ill 

Neuralgia of 112 

Obstruction of 120 



PAGE 

Intestines, Ulcers of 103 

Intussusception 122 

Invagination of Intestine 123 

Ipecacuanha in Dysentery 101 

J 

Jaundice 163,185, 193,201,212 

June Cold 875 

K 

Kidney, Amyloid 538 

Bright's Disease of 517 

Congestion of (Active) 515 

Congestion of ^Passive) 516 

Cancer of 555 

Dropsy of 553 

Hydatids of. 559 

Large White 517 

Movable 562 

Sclerosis of. 528 

Tuberculosis of. 558 

Knee-jerk 573 

L 

Landry's Paralysis 675 

Lardaceous Kidney. 538 

Liver 195 

Laryngismus Stridulus 491 

Laryngitis, Acute 476 

Chronic 478 

'■ Croupous 493 

Larynx, Diseases of 476 

Infiltration of 480 

Perichondritis of 48S 

Tumors of 489 

Leptomeningitis Spinalis 644 

Leucocythemia 229 

Leucaemia 229 

Liver, Abscess of 181 

Acute Yellovp Atrophy of 191 

Amyloid Disease of 195 

Cancer of 199 

Congestion of 169 

Hydatids of. 202 

• Inflammation of. 174, 181 

Sclerosis of. 174 

Lockjaw 721 

Lumbo-abdominal Neuralgia 733 

Lung-Fever 376 

Lungs, Cancer of 452 

Congestion of. 433 

Consumption of the 401 

Echinococcus of. 454 

Gangrene of 448 

Inflammation of. 376 

(Edema of 433 

Lymphadenoma 915 

Lympho-Sarcoma 915 

Lysis 385 

M 

Malarial Diseases . 885 

Eevers 885 

Malignant Anaemia 203 



GENERAL INDEX. 



985 



PAGE 

Malignant Cholera 833 

Lymphoma 915 

Massage.. 260,263 

Measles 772 

Medulla Oblongata, Diseases of the 682 

Haemorrhage of 632 

Inflammation of, Acute 634 

Inflammation of, Chronic 635 

Occlusion of Vessels 684 

Melaena Ill 

Melanaemia 241 

Melasma Suprarenale 235 

Membranous Bronchitis 465 

Croup 4S3 

Enteritis 91 

Meniere's Disease 626 

Meningeal Haemorrhage 696 

Meningitis, Acute 609 

Basilar 609 

of the Convexity 609 

Cerebro spinal 862 

Chronic . . 612 

Spinal 644 

Tubercular 605 

Miasmatic Diseases 838 

Micrococci 978 

Migraine 745 

Miliary Tuberculosis 906 

Mimetic Spasm 738 

Mitral Insufficiency 319 

Lesions 317 

Stenosis 317 

Morbus ^laculosus 251 

Morphine in Typhlitis and Peritonitis 84 

"Weak Heart 294, 327 

Movable Kidney 562 

Spleen 223 

Multiple Sclerosis of Brain and Cord , . . 677 

Mumps 852 

Muguet 6 

Myelitis, Acute 648 

Chronic 652 

Myocarditis 257 

Myxcedema 752 

S 

Nasal Catarrh 499 

Haemorrhage 502 

Naso-pharyngeal Catarrh 19 

Nematoda 188 

Nephritis 517 

Interstitial 528 

Parei.chymatous 517 

Nephrolithiasis 646 

Nerves. Atrophy of 729 

Inflammation of. 725, 727 

Syphilis of 691 

Neuralgia 729 

Cardiac 747 

Cervico-occipital 733 

Cervico-brachial 733 

Intercostal 733 

Lumbo-abdominal 733 

Trifacial 729 



PAGE 

Neurasthenia 707 

Neuritis Ascendens 725 

Descendens 725 

Progressive Multiple 727 

Neuroses, Cerebro-spinal 691 

Vaso-motor 745 

Noma ... 17 

Nutrition, Disorders of 901 



Obstruction of the Intestines 120, 121 

of the Bronchi 469 

Occlusion of Biliary Passages 214 

• Cerebral Vessels 581, 634 

OEdema of the Glottis 480 

of the Lungs 433 

CEsophagitis 23 

CEsophagus, Dilatation of 26 

Stenosis of 25 

Oligaemia 254 

I Ophthalmoscopy 666 

I Osteomalacia 909 

j Oxyurus Vermicularis 141 



Pachymeningitis 

Spinalis 

Palpitation of the Heart .. 

Pancreas, Calculi of 

Cancer of 

Cysts of 

Pancreatitis 

Paracentesis Thoracis 

Pericardii 

Paragraphia 

Paralysis, Acute Ascending 

Agitans , 

Bulbar 

Chronic Progressive 

General 

Glosso-labio-laryngeal 

Infantile 

Paraphasia 

Parasites 

Animal. 

Intestinal 

Vegetable 

Parenchymatous Hepatitis 181, 

Nephritis 

Nephritis, Chronic 

Parotiditis 

Pericardium, Adhesions of 

Dropsy of 

Inflammation of 

Pericarditis , 

Perinephric Abscess 

Perinephritis 

I'eripheral Nerves, Diseases of 

Periproctitis 

Peritonitis 

Chronic 

Suppurative 

Tubercular 

Perityphlitis 



597 
643 
330 
169 
158 
159 
155 
369 
283 
623 
675 
713 
634 
635 
681 
635 
664 
623 
978 
979 
131 
978 
191 
517 
524 
882 
283 
285 
273 
273 
564 
564 
725 

87 
143 
148 
164 
148 

8G 



GENERAL INDEX. 



PAGi; 

Pertussis 

Pharyngeal Catarrh 19 

Phosphate of Soda in Hepatic Calculi 219 

Phthisis 401 

Caseous 402 

Fibroid 416 

Florida 405 

Laryngeal 483 

— -Tubercular 406 

Pigment Embolisms 224, 2il, 586 

Pineapple Heart 275 

Plastic Endocarditis 301 

Pleurisy 355 

Chronic 359 

Haemorrhagic 357 

Purulent 357 

Pleuritis 355 

Pneumatic Treatment 447 

Pneumonia 376 

Catarrhal 394 

Croupous 376 

Fibrinous 376 

from Embolism 392 

Pneumonitis 376 

Pneumothorax 371 

Podagra 930 

Pohomyelitis Anterior Acuta 664 

Chronica 673 

Poliarthritis Eheumatica 920 

Polydipsia 948 

Polyuria 948 

Portal Vein, Suppurative Inflammation of 207 

Thrombosis of 208 

Posterior Spinal Sclerosis 655 

Proctitis 87 

Progressive Anjemia 263 

General Paralysis 681 

— : — Locomotor Ataxia 655 

Progressive Muscular Atrophy 668 

Muscular Atrophy, Pseudo-hypertrophic. . 672 

Prosopalgia 729 

Prune-juice Expectoration 381 

Pseudo-Croup 491 

Pulmonary Emphysema 440 

Haemorrhage 427 

Valves, Lesions of 322 

Purpura 251 

Haemorrhagica 251 

Simplex 251 

Pyelitis 543 

Pyelonephritis 543 

Pyrosis 86 

Q 

Quinine in Fevers 809 

as a Prophylactic 897 

E 

Kabies 966 

Pwachitis 909 

Eectum, Catarrh ot 87 

Recurrent Scarlatina 786 

Eeflexes 572 

Deep 573 



PAGE 

Pweflexes, Superficial 572 

Eegurgitation, Aortic 314 

Mitral 317 

Eelapsing Fever 817 

Eemittent Fever 895 

Eenal Calculi 546 

Colic 546 

Eheumatic Fever ^ 920 

Gout....- 936 

Eheumatoid Arthritis 936 

Eheumatism, Acute 920 

Chronic 928 

Eickets 909 

Eose-Cold 875 

Eoseola 778 

Eoetheln 778 

Roundworms 138 

Rubeola 772 

Diagnosis of 789 

Rupture of the Heart 293 

S 

Sarcina Ventriculi 36 

Scarlatina 779 

Scarlet Fever 779 

Sciatica 734 

Sclerosis of the Brain and Cord 677 

of the Kidney 528 

of the Liver 174 

of the Spine 677 

Scorbutus 246 

Scrivener's Cramp 719 

Scrofula 901 

Scurvy 246 

Shaking Palsy 713 

Shingles 734 

Sick- Headache 745 

Small -pox ■ 755 

Spasm of the Diaphragm 741 

I of the Eyelids 738 

of the Face 738 

of the Glottis 491 

Histrionic 738 

Spastic Spinal Paralysis 662 

Spinal Cord, Hyperaemia of 639 

Inflammation of 648 

Spinal Irritation 707 

Spinal Meningitis , . 644 

Sclerosis, Lateral 662 

Sclerosis, Posterior 655 

Spleen, Amyloid 224 

Echinococcus of. 224 

Enlargement of 222 

Misplaced 223 

Splenitis . 220 

Splenization of the Lungs 484 

Stenosis of Aortic Orifice 314 

of the Bronchi 469 

of the Mitral Orifice 317 

of the CEsophagus 25 

of the Pylorus 64 

of the Trachea , 469 

Stomach, Dilatation of. 64 

-. — Diseases of 27 



GENERAL INDEX. 



987 



PAGE 

Stomachal Vertigo 35, 36, 581 

Stomatitis 4 

Mercurial 4 

Struma 901 

Summer Catarrh 875 

Sunstroke 834 

Suppuration of the Tongue 10 

Suppurative Hepatitis 181 

Syphilis of the Nervous System 686 

Syphiloma of the Brain 686 

of the Cord 689 

of the Larynx 486 

of the Nerves 691 

T 

Tabes Dorsalis 655 

Spasmodic 662 

Taenia Echinococeus 204 

Saginata 134 

Solium 132 

Tape-worm 132 

Terminal Arteries 268, 311 

Tests for Sugar, 510, 946 

Tetanus T21 

Thrombosis and Embolism 45, 265 

of the Brain. 581 

of the Portal Vein 208 

Tic-Douloureux 729 

Thread-worms 141 

Tongue, Infiammation of 8 

Suppuration of. 10 

Tonsillitis 12 

Topography of the Abdomen 1 

of the Chest 349 

of the Heart 269 

of the Liver 160 

of the Spleen 220 

Torsion of the Bowel 122 

Torticollis 789 

Trachea, Stenosis of. 469 

Tremor 679 

Trichinae 970 

Trichinosis 970 

Trichocephalus Dispar 141 

Tricuspid Lesions 320 

Trismus 721 

Neonatorum 721 

Trommer's Test 510 

Trophic Neuroses 745 

Tubercular t 'onsumptijn 406 

Meningitis 605 

Tuberculosis, Acute 906 



PAGE 

Tuberculosis of the Kidney 558 

Tuberculous Ulcers of the Intestines 107 

Tufnell's Treatment of Aneurism 3-17 

Tumors of the Brain 617 

of the Larynx 489 

Typhlitis .' 81 

Typhoid Fever 795 

Typho-malarial Fever 810 

Typhus Fever 817 

U 

Ulcer of the Caecum 105 

of the Duodenum 103 

of the Intestines 103 

of the Stomach 44 

Ulcerative Endocarditis 305 

Uraemia 511 

Urinary Calculi 546 

Urine, Adventitious Substances in 508 

Urine in Acute Parenchymatous Nephritis 519 

in Chronic Parenchymatous Nephritis 525 

in interstitial Nephritis 533 

its Composition 503 

V 

Vaccinia 768 

Vaccination 768 

Valvular Lesions 309 

Varicella 771 

Variola 755 

Varioloid 765 

Vaso-motor and Trophic Neuroses 745 

Vertigo 626 

Vicarious Haemorrhage 49 

Vomiting of Blood 47, 56, 60 

in Abscess of the Liver 185 

W 

"Wandering Kidney 562 

Spleen 224 

Waxy Kidney 538 

Liver 195 

Whooping-Cough 879 

Winter-Fever 378 

"Worms. Intestinal 131 

Writer'^ Cramp 719 

"Wryneck 739 

Y 

Yellow Atrophy of the Liver 191 

Yellow Fever , 822 



IKDEX OF AUTHORS. 



PAGE 

Ahmed 178 

Aitken 831 

Allbutt 533, 607 

Althaus 737 

Ancelet 158 

Anstie 780 

Armor, S. G 134 

Ashhurst... 131 

Auspitz and Basch 756 

Averbeck 235 

Axenfeld 707 

Bacon 618 

Balfour 317, 318 

Ball 9 

Bamberger 164, 2T4 

Barker, Fordyce 499 

Bartles 529 

Bartholow 106, 618, 776, 846 

Beard 707 

Beale 547 

Bert 472 

Bennett, Hughes 229, 390 

Becquerel and Rodier 225, 254 

Besnier 154 

Billroth 221, 919 

Blackley 875 

Bouchut 707 

Brinton 55 

Bristowe 328, 625 

Broca 623 

Bryant 128 

Brunton 170, 939 

Buck, Gurdon 87, 483 

Buckler, T.H 219 

Budd 164, 182 

Budd, George, Jr 195, 539 

Buhl 236 

Bulkley 751 

Burdon-Sanderson 850, 864 

Cameron 190 

Carter, Vandyke 547 

Cayley 174 

Charcot and Joflfroy 663, 669 

Charcot 76, 176, 211, 517, 677 

Cheadle 638 



PAGE 

Clark, Sir Andrew 418, 752 

Clarke, J. Lockhart 292, 635 

Coates 193 

Cobbold 137,132 

Cohnheim 208, 392,427, 582, 960, 971 

Cohn 184 

C(mdon 190 

Cornil 176 

Corrigan 315 

Cotton 331 

Crisp 849 

Crumb 189 

Cruveilhier 53 

Curschmann 753 

Da Costa 92,158,529 

Davaine 131, 136, 203, 455, 973 

Dax 624 

Dickinson 529, 539, 926, 941 

Dickson, S. H 831 

Doremus 505 

Dowse 633 

Drake 885 

Duchenne 635 

Durham 207 

Earle ; 156 

Eborth 306,851 

Ebstein 550 

Echeverria 692 

Eichler 589 

Ei?hhorst 727 

Elischer 717 

Elhot, George T 522 

Frb 635, 656, 672, 737 

Eulenberg 570, 716,737 

Fagge, Hilton 207 

Fayrer 183,329 

Fenger 456 

Fenner 831 

Fenwick 189, 415 

Fere et Demars 631 

Terrier 624 

Finkentscher C2 

Flint, Austin 324 

Fliut, Austin, Jr 194, 225 



INDEX OF AUTHORS. 



989 



PAGE 

riechsig- 591 

Forster 53, 1S3, 196, 199 

Foster, B .....944 

Fothergill 824, 843 

Fox, Wilson 44 

Frantzel 295 

Frerichs.. 164, 170, 182, 196 

Friedreich 635, 656, 659, 669 

Fritschand Hitzig 624 

FTommhold 147 

Fuller 924 

Gairdner 346 

GaU 624 

Garrod 246,938 

Gee 507, 913 

Githens 866 

Glasgow 486 

Gowers 232, 694, 917 

Grandidier 244, 2-15, 781 

Green 505 

Greenhow 236 

Gregory 78.3 

Griffith 174 

GuU 232, 752, 857 

Gull and Sutton 924 

Guttmann 818 

Habershon 454 

Hammond 260, 575 

Harley 162, 164, 506 

Hayem 669 

Heiberg ^ . 122 

Heidenhain 164 

Heller 132,971 

Henle 271, 5S8 

Hodgkin 915 

Hoppe-Seyler 58, 937 

Huebner 688 

Haeter 847 

Huguenin 193 

Hunt 863 

Hutchison 62,128,837,938 

Hutchison, James H 837 

Immermann 243, 251 

Jackson, Hughlings 620, 696 

Jaccoud 95, 283, 304, 377, 796. 892 

Jacobi, Mary Putnam 665 

Jaffe 58, 851 

Jarvis 839 

Jenner 857,910 

Jewell 703 

Joffroy 727 

Johnson, George 340, 517 

Jones, Handfield 60 

Jones, Joseph 890 

Jiirgensen 390 

Kelsch et Kiener 210 

Key, Axel . .338 

Klebs 377, 801, 865 

Klebs und Tommasi-Crudeli 885 



PAGE 

Knapp 573 

Kolliker 236 

Krauss 104 

Kreminansky 598 

Kuchenmeister 136, 203 

Kiihne 155 

Kussmaul 623, 664 

Kussmaul and Tenner 244, 256, 578 

Kiister 66 

Kuttner 122 

Ladame 619, 621 

Laucereaux 687 

Langhaus 916 

Lawson 735 

La Roche S24. 826 

Leared 309 

Lebedefif. 536 

Lfbert 818 

Le^g, Wiekham 145, 211, 243 

Laycock 950 

Leichtenstern 129 

Letzerich 849 

Leube , 66 

Levick 834 

Lewitski 192 

Leyden 635 

Lidell 864 

Liebermeister 180, 795 

Lombard 72, 408, 494, 754 

Longstreth 529 

Loomis 601, 796 

Luton 54 

Lyons 797, 813, 824 

Maclean 183, 295 

Maier 307 

Magnus 522, 786 

Mason 131 

McConnell 188 

Meniere 631 

Merkel 103,236 

Meynert 692, 717 

Mitchell, Weir 260, 660, 670 

Morand 194 

Morvan 752 

Mosler 230 

Moxon 31, 164, 182, 689 

Murchison 174, 182, 815 

Narcom 533 

Niemeyer 439 

Oertel 847,854,860 

Ogle, J. W 323, 329, 618, 632 

Oliver 162 

(Jllivier et Eanvier 232 

Oppolzer 155, 497 

Ord 547,752 

Orth 23,196 

Pavy 947 

Parkes 890 

Parry 813 



990 



INDEX OF AUTHORS. 



PAGE 

Perl 291 

Ponfick 289, 291, 293, 536 

Poore 719 

Porter 233 

Eadcliffe, Netten 869 

Kalfe 538 

Eemak 737 

Eenaut 23 L 

Eendu 195 

Eeyher 921 

Eeynolds. Eussell 692 

Eichardson, J. G 825 

Eieg-el 466 

Eiess 822 

Eigal 184, 185 

Eindfleisch 53, 230, 241, 375, 333, 377, 598 

Einger 923 

Eoberts 552, 560 

Eoberts,J.D 286 

Eomberg 694 

Eokitansky 58, 183 

Eosenthal 645 

Eossbach... 239 

Eiidinger... 1, 4 

EulofiF 911 

Eutherford 210 

Sachs 181, 190, 191 

Salkowski 472 

Salter, Hyde 446 

Saundby 529 

Schitf 164 

Schmidt 825 

Schroeder van der Kolk 692 

Schutz 910 

Seguin 666 

Senator. 909, 920 

Shea 140 

Sibson 336, 346 

Sinkler 654 

Smith, A. H 51 

Smith, Pye 121 

Sparks and Bruce 535 



PAGE 

Squire 854 

Steiner 497 

Sternberg 826 

Stewart, Grainger 183 

Stille 864 

Stokes 812 

Street 466 

Sutton, George 972 

Taylor 343 

Thierfelder. 404, 407, 442 

Thompson 274 

Thudichum 215 

Topinard 656 

Traube 361 

Treitz 121 

Trousseau 123, 130, 164, 635, 796, 814 

Tufnell 847 

Turpin 638 

Van der Kolk, Schroeder 692 

Vidaillet 626 

Virchow 183, 205, 236, 260, 484, 848 

Vulpian 652, 729 

"Wachsmuth 635 

Wagner 196, 200, 231, 261 

Waldenburg 447,471 

Waldeyer 53, 192, 555 

Waring 182, 184 

Weber 472 

Wells, Spencer f 55 

Westphalen 169 

Whipham 306 

Wilks 31, 236, 239, 931 

Williams 441, 471 

Wintrich 471 

Wood hull 823 

Wood, G. B 795, 863 

Woodward 810 

Wyman, Morrill 875 

Teo,Burney 345 



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The New York Medical Journal and The Popular Science Monthly to 
the same address, $9.00 per annum (full price, $10.00). 



D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. 



